2015-09-22 14:27:12

  1. 1. Initial Data Load
    1. 1.1. Juana Mariana Gonzales Initial Data Load
      1. 1.1.1. Enter Initial Demographic Data for New Patient Juana Mariana Gonzales, 6-year old
      2. 1.1.2. Enter Initial Immunization Data for Juana Mariana Gonzales: Immunizations from practice
      3. 1.1.3. Enter Initial Immunization Data for Juana Mariana Gonzales from Another Practice
      4. 1.1.4. Enter Initial Immunization Data for Juana Mariana Gonzales Reported by Parent
      5. 1.1.5. Enter Adverse Reaction to the Polio Vaccine
      6. 1.1.6. Enter allergy to egg albumin
      7. 1.1.7. Enter HepB Dose1 and 3 of 3
      8. 1.1.8. Enter DTaP Doses 1, 2, 3 and 4 of 5
      9. 1.1.9. Enter Hib Doses 1-4 of 4
      10. 1.1.10. Enter Polio Dose1 and 2 of 4
      11. 1.1.11. Enter Pneumococcal,Doses 1-4 of 4
      12. 1.1.12. Enter Rotavirus Dose1 and 2 of 3
      13. 1.1.13. Enter Influenza History Doses
      14. 1.1.14. Enter HepA Dose1 and 2 of 2
      15. 1.1.15. Enter MMRV Dose1 and 2 of 3
    2. 1.2. Juan Marcel Gonzales Initial Data Load
      1. 1.2.1. Enter Initial Demographic Data for New Patient Juan Marcel Gonzales
      2. 1.2.2. Enter Clinical History for Juan Marcel Gonzales
      3. 1.2.3. Enter HepB Dose1 and 2 of 3
      4. 1.2.4. Enter DTaP Doses 1-4 of 5 Juan Marcel
      5. 1.2.5. Enter Hib Doses 1-4 of 4 Juan Marcel
      6. 1.2.6. Enter Polio Dose1-3 of 4 Juan Marcel
      7. 1.2.7. Enter Pneumococcal,Doses 1-4 of 4 Juan Marcel
      8. 1.2.8. Enter Rotavirus Dose1 and 2 of 3 Juan Marcel
      9. 1.2.9. Enter Influenza History Doses Juan Marcel
      10. 1.2.10. Enter HepA Dose1 and 2 of 2 Juan Marcel
      11. 1.2.11. Enter MMRV Dose1 of 3 Juan Marcel
    3. 1.3. Mariela Gonzales Morales Initial Data Load
      1. 1.3.1. Enter Initial Demographic Data for Mariela Gonzales Morales
      2. 1.3.2. Enter Initial Clinical Information for Mariela
      3. 1.3.3. Enter HepB Dose1 of 3 Mariella
    4. 1.4. Juana Maria Gonzales Morales Initial Data Load
      1. 1.4.1. Enter Initial Demographic Data for Juana Maria Gonzales Morales
      2. 1.4.2. Enter HepB Dose1 of 3 Juana Maria
  2. 2. Display Immunization History and Forecast
    1. 2.1. Juana Mariana Gonzales Display Immunization History and Forecast
      1. 2.1.1. Display the Evaluated Immunization History
      2. 2.1.2. View the vaccination forecast for Juana Mariana Gonzales
    2. 2.2. Juan Marcel Gonzales Display Immunization History and Forecast
      1. 2.2.1. Display the Evaluated Immunization History for Juan Marcel Gonzales
      2. 2.2.2. View the vaccination forecast for Juan Marcel Gonzales
    3. 2.3. Mariela Gonzales Morales Display Immunization History and Forecast
      1. 2.3.1. Display the Evaluated Immunization History for Mariela Gonzales Morales
      2. 2.3.2. View the vaccination forecast for Mariela Gonzales Morales
    4. 2.4. Juana Maria Gonzales Morales Display Immunization History and Forecast
      1. 2.4.1. Display the Evaluated Immunization History for Juana Maria Gonzales Morales
      2. 2.4.2. View the vaccination forecast for Juana Maria Gonzales Morales
  3. 3. Order and Immunize patient
    1. 3.1. Juana Mariana Gonzales, Enter Orders and Immunizations
      1. 3.1.1. Order IPV and view prior reaction
      2. 3.1.2. IPV Parental Refusal
      3. 3.1.3. Order Influenza vaccine and view allergy alert
      4. 3.1.4. Order MMRV Vaccine
      5. 3.1.5. Records Influenza Vaccine administration route with data validation checking
      6. 3.1.6. Record Influenza Vaccine administration
      7. 3.1.7. Records MMRV Vaccine administration route with data validation checking
      8. 3.1.8. Record MMRV Vaccine administration
    2. 3.2. Juan Marcel Gonzales, Enter Orders and Immunizations
      1. 3.2.1. Order intranasal, live virus influenza vaccine and view asthma contraindication
      2. 3.2.2. Orders administration of Hepatitis B vaccine
      3. 3.2.3. Orders administration of DTaP vaccine and alerted that the dose is too early
      4. 3.2.4. Records Hepatitis B Vaccine lot number with expired lot alert
      5. 3.2.5. Record Hepatitis B Vaccine administration
      6. 3.2.6. Records Influenza Vaccine administration with VFC eligibility checking
      7. 3.2.7. Record Influenza Vaccine administration for Juan Marcel Gonzales
    3. 3.3. Mariela Gonzales Morales, Enter Orders and Immunizations
      1. 3.3.1. Enters a deferral for the vaccines due
  4. 4. Transmit Immunization Report
    1. 4.1. Juana Mariana Gonzales Transmit Immunization Report
      1. 4.1.1. Transmit the immunization report to the Immunization Registry
      2. 4.1.2. Record an adverse reaction
      3. 4.1.3. Transmit the updated vaccination report with adverse reaction to the registry
    2. 4.2. Juan Marcel Gonzales Transmit Immunization Report
      1. 4.2.1. Transmit the Immunization Report for Juan Marcel Gonzales
    3. 4.3. Mariela Gonzales Morales Transmit Immunization Report
      1. 4.3.1. Transmit the Immunization Report for Mariela Gonzales Morales
  5. 5. Display Immunization Report
    1. 5.1. Juana Mariana Gonzales Display Immunization Report
      1. 5.1.1. Produce an immunization report for Juana Mariana Gonzales including all history
    2. 5.2. Juan Marcel Gonzales Display Immunization Report
      1. 5.2.1. Produce an immunization report for Juan Marcel Gonzales including all history
    3. 5.3. Mariana Gonzales Morales Display Immunization Report
      1. 5.3.1. Produce an immunization report for Juan Marcel Gonzales including all history
  6. 6. Cohort Report
    1. 6.1. Overdue Immunizations
      1. 6.1.1. Produce Overdue Immunizations Cohort Report

1. Initial Data Load

The initial Data load will consist of the vendor entering data during live interactive testing for 4 patients with various scenarios. The data entry will include demographic data, Immunization histories and specific conditions for each patient.

1.1. Juana Mariana Gonzales Initial Data Load

Demonstrates the ability to record pediatric demographic data, historical vaccinations, and clinical conditions for 6-year old Juana Mariana Gonzales. There are no transactions associated with this test case.

Test Story

Description

The practice site for the scenario is Shoreline Pediatrics. The EHR vendor loads demographic data and clinical history for Juana Mariana Gonzales. The data includes immunizations provided by the practice.

The vendor also enters:

? Two vaccines administered at other sites

? ?o an influenza vaccine given at a local pharmacy

? ?o an inactivated polio vaccine given elsewhere and not reported to the registry ? the history includes an adverse reaction (febrile seizure) 8 hours after the vaccine was administered

? Adverse reaction to inactivated polio vaccine (febrile seizure) and the date and source of information

? Allergy to egg albumin administered at this site (the registry has different CVX date and lot number information for this vaccine)

NOTE: the historical vaccines will be imported during the Registry query ?(e.g. from another practice)

Comments
Set-up step evaluating EMR functions for capturing and storing patient pediatric demographic data, historical immunizations, and clinical conditions. There is no transaction associated with this test step.

PreCondition
No PreCondition

PostCondition
The EMR has recorded all of the pediatric demographic data, historical immunizations, and clinical conditions ?in the record created for Juana Mariana Gonzales?using the test data provided.

Test Objectives
No Test Objectives

Evaluation Criteria
No evaluation criteria

Notes to Testers
No Note

1.1.1. Enter Initial Demographic Data for New Patient Juana Mariana Gonzales, 6-year old

Test Step Type: SUT_MANUAL
Juana Mariana Gonzales is entered as a patient in the EMR, including all pediatric demographic information.

Test Story

Description

The EHR vendor loads demographic data for Juana Mariana Gonzales.

Comments

Set-up step evaluating EMR functions for capturing and storing patient pediatric demographic data. There is no transaction associated with this test step.

PreCondition

No PreCondition

PostCondition

The EMR has recorded all of the pediatric demographic  in the record created for Juana Mariana Gonzales.

Test Objectives

Register New Patients: The system must allow a user to enter distinguishing information about patients so that providers can uniquely identify patients who have similar sounding names or other similar identifying information.  For example, twins living in the same household will have similar dates of birth, addresses, and may have similar names. EHRs or other clinical software must be able to store information to successfully match with patients in immunization registries, if the information is available. The information includes the mother’s maiden name, whether the patient was part of a multiple birth, and the order of the multiple birth. This information allows the provider to correctly identify the patient and also helps assure a match when the EHR send the patient’s information to external systems such as an immunization registry.

Evaluation Criteria

Evaluation Criteria: Vendor successfully records all demographic data provided, and in particular (Mother's maiden name, multiple birth, birth order), with all required attributes indicated by [Y]:

Patient ID (previously listed as “Medicaid Number”) Vendor supplied Y
Patient ID: Assigning Authority ID (i.e., owning source)/Facility Name Shoreline Pediatrics Y
Patient ID: Type (e.g., medical record number, IIS ID) Vendor supplied Y
Patient Name: First  Juana Y
Patient Name: Middle Mariana Y
Patient Name: Last Gonzales Y
Patient Date of Birth 12/23/2009 Y
Birth Time 11:05 N
Patient Gender (Administrative Sex) F Y
Patient Multiple Birth Indicator No Y
Patient Birth Order NA C
Responsible Person Name: First Joanna Y
Responsible Person Name: Middle Merida Y
Responsible Person Name: Last Gonzales Y
Responsible Person Name: Relationship to Patient Grandmother Y
Mother’s Name: First Maria Y
Mother’s Name: Middle Merida Y
Mother’s Name: Last Gonzales Y
Mother’s Name: Maiden Last Acosta Y
Patient Address: Street 4345 Standish Way Y
Patient Address: City Stamford Y
Patient Address: State CT Y
Patient Address: Country USA Y
Patient Address: Zipcode 06903 Y
Patient Address: County of Residence Fairfield N
Race Other Y
Ethnicity Hispanic or Latino Y
Birthing Facility Name (Birth Delivery Location Address BDL) Shoreline Hospital
325 Shorline Drive, Stamford Connecticut 06901		 [Y - birthing facility name, not address]
Patient Birth State CT Y
Patient Primary Language English Y
Patient Telephone Number (203) 555-1212 Y
Patient Telephone Number Type (e.g., home, cell) home Y
Patient E-mail Address jmg@gmail.com N
Publicity Code   N
Protection Indicator   N
Protection Indicator Effective Date   N
Immunization Registry Status   N
Preferred Contact Method Phone Y

Notes to Testers

No Note

1.1.2. Enter Initial Immunization Data for Juana Mariana Gonzales: Immunizations from practice

Test Step Type: SUT_MANUAL
Patient History from the local practice is entered into the EMR.

Test Story

Description

The EHR vendor loads immunization history data from the local practice for Juana Mariana Gonzales.

Comments

No Comments

PreCondition

The EMR has recorded all of the pediatric demographic in the record created for Juana Mariana Gonzales.

PostCondition

The immunization history  the known to the local practice is loaded into the record created for Juana Mariana Gonzales.

Test Objectives

Record Past Immunizations: The EHR or other clinical software system allows providers to enter information about immunizations given elsewhere (e.g., by another doctor, at a public health clinic, pharmacy, etc.) with incomplete details.

Evaluation Criteria

Evaluation Criteria: Vendor successfully records all immunization data known to the local practice as provided, with all required attributes indicated by [Y]:

Vaccine from Practice HepB    
Entered BY Sandra Molina Y
Ordering Provider Frank Smith Y
Entering Organization Shoreline Pediatrics Y
Administration Notes (Vaccine Event information source) New immunization record (NIP001 00) Y
Date/Time of Start of Administration 1/15/2010 Y
Vaccine Administered hepatitis B vaccine, pediatric or pediatric/adolescent dosage  (CVX 08) Y
Administered Amount (of Vaccine) 0.5 Y
Administered Units (of Measure) mL Y
Administering Provider Sandra Molina Y
Administered-at Location 400 Shoreline Drive, Stamford Connecticut 06901 Y
Lot Number 6352FK1 Y
Substance Expiration Date 10/1/2010 Y
Substance Manufacturer Name GlaxoSmithKline Biologicals SA (MVX SKB) Y
Completion Status CP Y
Route of Administration IM Y
Administration Site Right Thigh Y
     
Vaccine from Practice MMRV    
a. Entered BY J. Martinez Y
b. Ordering Provider Frank Smith Y
c. Entering Organization Shoreline Pediatrics Y
Vaccine Event information source New immunization record (NIP001 00) Y
Value/Text for Vaccine Type  MMRV Y
Date/Time of Start of Administration 10/23/2010 Y
Vaccine Administered measles, mumps, rubella, and varicella virus vaccine Y
Administered Amount (of Vaccine) 0.5 Y
Administered Units (of Measure) mL Y
Administering Provider
Sandra Molina Y
Administered-at Location
400 Shoreline Drive, Stamford Connecticut 06901
Y
Lot Number 7W27V7491 Y
Substance Expiration Date 12/15/2010 Y
Substance Manufacturer Name Merck Sharp & Dohme Corp (MVX MSD) Y
Completion Status CP Y
Route of Administration Intramuscular (NCIT IM) Y
Administration Site Right Thigh (HL70163 RT)  

Notes to Testers

No Note

1.1.3. Enter Initial Immunization Data for Juana Mariana Gonzales from Another Practice

Test Step Type: SUT_MANUAL
Patient History from another practice is entered into the EMR.

Test Story

Description

The EHR vendor loads immunization history data from another practice into the record for Juana Mariana Gonzales.

Comments

No Comments

PreCondition

The EMR has recorded all of the pediatric demographic  in the record created for Juana Mariana Gonzales.

PostCondition

The immunization history from another practice is loaded into the record created for Juana Mariana Gonzales.

Test Objectives

Record Past Immunizations: The EHR or other clinical software system allows providers to enter information about immunizations given elsewhere (e.g., by another doctor, at a public health clinic, pharmacy, etc.) with incomplete details.

Evaluation Criteria

Evaluation Criteria: Vendor successfully records all immunization history data from another practice as provided, with all required attributes indicated by [Y]:

Historical Vaccine from Another Practice - Dtap    
Entered BY Sandra Molina Y
Ordering Provider J. Rodriguez Y
Entering Organization Shoreline Pediatrics Y
Vaccine Event information source (Administration Notes) Historical information - from parent’s written record (NIP001 03) Y
Value/Text for Vaccine Type  DTaP Y
Date/Time of Start of Administration 8/31/2014 Y
Vaccine Administered diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) Y
Administered Amount (of Vaccine) 0.5 Y
Administered Units (of Measure) mL Y
Administering Provider Linda Casera Y
Administered-at Location 4253 Standish Way, Stamford Connecticut 06903 Y
Lot Number D643QS8243 Y
Substance Expiration Date 9/1/2014 Y
Substance Manufacturer Name Sanofi Pasteur Inc (MVX PMC) Y
Completion Status CP Y
Route of Administration Intramuscular (NCIT IM) Y
Administration Site Left Deltoid (HL70163 LD) Y
     
Historical Vaccine from Another Practice - Polio    
Entered BY Sandra Molina Y
Ordering Provider J. Rodriguez Y
Entering Organization Shoreline Pediatrics Y
Vaccine Event information source Historical information - from parent’s written record (NIP001 03) Y
Value/Text for Vaccine Type 
poliovirus vaccine, inactivated (CVX 10)
Y
Date/Time of Start of Administration 2/21/2011 Y
Vaccine Administered poliovirus vaccine, inactivated (CVX 10) Y
Administered Amount (of Vaccine) 0.5 Y
Administered Units (of Measure) mL Y
Administering Provider Linda Casera Y
Administered-at Location 4253 Standish Way, Stamford Connecticut 06903 Y
Lot Number D335PV9644 Y
Substance Expiration Date 2/22/2011 Y
Substance Manufacturer Name Sanofi Pasteur Inc (MVX PMC) Y
Completion Status CP Y
Route of Administration Intramuscular (NCIT IM) Y
Administration Site Left Deltoid (HL70163 LD) Y
Reaction VXC12^fever of >40.5C (105F) within 48 hours of dose^CDCPHINVS Y

Notes to Testers

No Note

1.1.4. Enter Initial Immunization Data for Juana Mariana Gonzales Reported by Parent

Test Step Type: SUT_MANUAL
Patient History from a pharmacy as reported by the parent is entered into the EMR.

Test Story

Description

The provider enters immunization data from a pharmacy as reported by the parent for Juana Mariana Gonzales.

 

Comments

No Comments

PreCondition

The EMR has recorded all of the pediatric demographic data  in the record created for Juana Mariana Gonzales.

PostCondition

The immunization history from the pharmacy as reported by the parent is loaded into the record created for Juana Mariana Gonzales.

Test Objectives

Record Past Immunizations: The EHR or other clinical software system allows providers to enter information about immunizations given elsewhere (e.g., by another doctor, at a public health clinic, pharmacy, etc.) with incomplete details.

Evaluation Criteria

Evaluation Criteria: Vendor successfully records all immunization history data from the pharmacy as provided by the parent with all required attributes indicated by [Y]:

Historical Vaccine from Pharmacy Reported by Parent    
Entered BY Sandra Molina Y
Ordering Provider Gina Ricci Y
Entering Organization Shoreline Pediatrics Y
Vaccine Event information source (Administration Notes) Historical information - from other provider (NIP001 02) Y
Value/Text for Vaccine Type  Influenza vaccine Y
Date/Time of Start of Administration 10/15/2013 Y
Vaccine Administered influenza, live, intranasal, quadrivalent (CVX 149) FluMist Quadrivalent (NDC 66019-0301-10)) Y
Administered Amount (of Vaccine) 0.5 Y
Administered Units (of Measure) mL Y
Administering Provider Gina Ricci Y
Administered-at Location Oceanview Pharmacy, 15 Post Road, Stamford Connecticut 06901 Y
Lot Number 8L4B3423 Y
Substance Expiration Date 7/1/2014 Y
Substance Manufacturer Name MedImmune, LLC (MVX MED) Y
Completion Status CP Y
Route of Administration Nasal (NCIT NS) Y
Administration Site   Y

Notes to Testers

No Note

1.1.5. Enter Adverse Reaction to the Polio Vaccine

Test Step Type: SUT_MANUAL
The EHR captures structured data regarding adverse events as part of the clinical history.

Test Story

Description

The provider documents in the EMR the clinical history of an adverse reaction to the polio vaccine.

Comments

No Comments

PreCondition

The EMR has recorded all of the pediatric demographic in the record created for Juana Mariana Gonzales.

PostCondition

The clinical history of the adverse reaction to the Polio vaccine is documented in the the record created for Juana Mariana Gonzales.

Test Objectives

Identify Adverse Event: The EHR or other clinical software system enables capture of structured data regarding adverse events.

Evaluation Criteria

Evaluation Criteria: Vendor successfully records all demographic data provided with all required attributes indicated by [Y]:

Adverse Reaction Substance/Agent inactivated polio vaccine (e.g. Poliomyelitis vaccine adverse reaction (disorder) 293117006) Y
Reaction febrile seizure (e.g. Simple febrile seizure (finding) 432354000)
VXC11^convulsions (fits, seizures) within 72 hours of dose^		 Y
Date (of the reaction) 8/31/2014 Y

Notes to Testers

No Note

1.1.6. Enter allergy to egg albumin

Test Step Type: SUT_MANUAL
The EHR captures structured data regarding allergies as part of the clinical history.

Test Story

Description

The provider documents in the EMR the clinical history of an allergy to egg albumin.

Comments

No Comments

PreCondition

The EMR has recorded all of the pediatric demographic in the record created for Juana Mariana Gonzales.

PostCondition

The clinical history of the allergy to egg albumin is documented in the record created for Juana Mariana Gonzales

Test Objectives

Supporting data for: Modify Antigen Recommendations Based on Allergy History: The system notifies the provider of any conflicts between recommended vaccines in the updated forecast and the patient’s active allergies. 

Evaluation Criteria

Evaluation Criteria: Vendor successfully records all clinical allergy data provided with all required attributes indicated by [Y]:

Allergy Sugstance/Agent Egg Albumin Allergy (e.g. 213020009 Egg protein allergy (disorder), Allergy to eggs (disorder) 91930004) Y
Date (allergy status known - e.g. thru testing or date of the allergy) 8/31/2014 Y

Notes to Testers

No Note

1.1.7. Enter HepB Dose1 and 3 of 3

Test Step Type: SUT_MANUAL
Patient History for HepB is entered into the EMR.

Test Story

Description

The EHR vendor loads HepB immunization history data  for Juana Mariana Gonzales.

Comments

No Comments

PreCondition

The EMR has recorded all of the pediatric demographic in the record created for Juana Mariana Gonzales.

PostCondition

The immunization history for HepB known to the local practice is loaded into the record created for Juana Mariana Gonzales.

Test Objectives

Record Past Immunizations: The EHR or other clinical software system allows providers to enter information about immunizations given elsewhere (e.g., by another doctor, at a public health clinic, pharmacy, etc.) with incomplete details.

Evaluation Criteria

Evaluation Criteria: Vendor successfully records all immunization data known to the local practice as provided, with all required attributes indicated by [Y]:

HepB Dose 1 of 3    
Entered BY Sandra Molina Y
Ordering Provider Jane Carter Y
Entering Organization Shoreline Pediatrics Y
Administration Notes (Vaccine Event information source) Historical Immunization (NIP001 01) Y
Date/Time of Start of Administration 12/23/2009 Y
Vaccine Administered hepatitis B vaccine, pediatric or pediatric/adolescent dosage  (CVX 08) Y
Administered Amount (of Vaccine) 0.5 Y
Administered Units (of Measure) mL Y
Administering Provider Jane Carter Y
Administered-at Location 325 Shorline Drive,  Stamford Connecticut 06901 Y
Lot Number 6332FK33 Y
Substance Expiration Date 12/14/2010 Y
Substance Manufacturer Name GlaxoSmithKline Biologicals SA (MVX SKB) Y
Completion Status CP Y
Route of Administration Intramuscular (NCIT C28161, HL70162: IM) Y
Administration Site Left Thigh (HL7 LT) Y
     
HepB Dose 3 of 3    
Entered BY Sandra Molina Y
Ordering Provider Carlos Herrera Y
Entering Organization Shoreline Pediatrics Y
Vaccine Event information source Historical Immunization (NIP001 01) Y
Value/Text for Vaccine Type  hepatitis B vaccine, pediatric or pediatric/adolescent dosage  (CVX 08) Y
Date/Time of Start of Administration 10/30/2010 Y
Vaccine Administered hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08)
ENGERIX-B (NDC 58160-0820-11)		 Y
Administered Amount (of Vaccine) 0.5 Y
Administered Units (of Measure) mL Y
Administering Provider
J. Martinez Y
Administered-at Location
333 Oceanview Lane, Stamford Connecticut 06901
Y
Lot Number 6352FK24 Y
Substance Expiration Date 8/31/2012 Y
Substance Manufacturer Name GlaxoSmithKline Biologicals SA (MVX SKB) Y
Completion Status CP Y
Route of Administration Intramuscular (NCIT IM) Y
Administration Site Left Thigh (HL7 LT)  

Notes to Testers

No Note

1.1.8. Enter DTaP Doses 1, 2, 3 and 4 of 5

Test Step Type: SUT_MANUAL
Patient History for DTaP is entered into the EMR.

Test Story

Description

The EHR vendor loads DTaP  immunization history data  for Juana Mariana Gonzales.

Comments

No Comments

PreCondition

The EMR has recorded all of the pediatric demographic in the record created for Juana Mariana Gonzales.

PostCondition

The immunization history for DTaP known to the local practice is loaded into the record created for Juana Mariana Gonzales.

Test Objectives

Record Past Immunizations: The EHR or other clinical software system allows providers to enter information about immunizations given elsewhere (e.g., by another doctor, at a public health clinic, pharmacy, etc.) with incomplete details.

Evaluation Criteria

Evaluation Criteria: Vendor successfully records all immunization data known to the local practice as provided, with all required attributes indicated by [Y]:

DTaP Dose 1 of 5    
Entered BY Sandra Molina Y
Ordering Provider Carlos Herrera Y
Entering Organization Shoreline Pediatrics Y
Administration Notes (Vaccine Event information source) Historical Immunization (NIP001 01) Y
Date/Time of Start of Administration 1/22/2010 Y
Vaccine Administered diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)
DAPTACEL (NDC 49281-0286-01)		 Y
Administered Amount (of Vaccine) 0.5 Y
Administered Units (of Measure) mL Y
Administering Provider Y
Administered-at Location 333 Oceanview Lane, Stamford Connecticut 06901 Y
Lot Number D409QS2341 Y
Substance Expiration Date 11/30/2011 Y
Substance Manufacturer Name Sanofi Pasteur Inc (MVX PMC) Y
Completion Status CP Y
Route of Administration Intramuscular (NCIT C28161, HL70162: IM) Y
Administration Site Left Thigh (HL7 LT) Y
     
DTaP Dose 2 of 5    
Entered BY Sandra Molina Y
Ordering Provider Carlos Herrera Y
Entering Organization Shoreline Pediatrics Y
Vaccine Event information source Historical Immunization (NIP001 01) Y
Value/Text for Vaccine Type  diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)
DAPTACEL (NDC 49281-0286-01)		 Y
Date/Time of Start of Administration 3/23/2010 Y
Vaccine Administered diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)
DAPTACEL (NDC 49281-0286-01)
ENGERIX-B (NDC 58160-0820-11)		 Y
Administered Amount (of Vaccine) 0.5 Y
Administered Units (of Measure) mL Y
Administering Provider
J. Martinez Y
Administered-at Location
333 Oceanview Lane, Stamford Connecticut 06901
Y
Lot Number D409QS2433 Y
Substance Expiration Date 9/4/2011 Y
Substance Manufacturer Name Sanofi Pasteur Inc (MVX PMC) Y
Completion Status CP Y
Route of Administration Intramuscular (NCIT IM) Y
Administration Site Right Thigh (HL7 RT)  
Adverse Reaction 31044-1 Reaction, VXC12^fever of >40.5C (105F) within 48 hours of dose  
     
DTaP Dose 3 of 5  
Entered BY Sandra Molina
Ordering Provider Carlos Herrera
Entering Organization Shoreline Pediatrics
Vaccine Event information source Historical Immunization (NIP001 01)
Value/Text for Vaccine Type  diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)
DAPTACEL (NDC 49281-0286-01)
Date/Time of Start of Administration 5/22/2010
Vaccine Administered diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)
DAPTACEL (NDC 49281-0286-01)
ENGERIX-B (NDC 58160-0820-11)
Administered Amount (of Vaccine) 0.5
Administered Units (of Measure) mL
Administering Provider
J. Martinez
Administered-at Location
333 Oceanview Lane, Stamford Connecticut 06901
Lot Number D409QS3255
Substance Expiration Date 12/1/2010
Substance Manufacturer Name Sanofi Pasteur Inc (MVX PMC)
Completion Status CP
Route of Administration Intramuscular (NCIT IM)
Administration Site Left Thigh (HL7 LT)
DTaP Dose 4 of 5  
Entered BY Sandra Molina
Ordering Provider Carlos Herrera
Entering Organization Shoreline Pediatrics
Vaccine Event information source Historical Immunization (NIP001 01)
Value/Text for Vaccine Type  diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)
DAPTACEL (NDC 49281-0286-01)
Date/Time of Start of Administration 2/21/2011
Vaccine Administered diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)
DAPTACEL (NDC 49281-0286-01)
ENGERIX-B (NDC 58160-0820-11)
Administered Amount (of Vaccine) 0.5
Administered Units (of Measure) mL
Administering Provider
J. Martinez
Administered-at Location
333 Oceanview Lane, Stamford Connecticut 06901
Lot Number D409QS249
Substance Expiration Date 3/1/2011
Substance Manufacturer Name Sanofi Pasteur Inc (MVX PMC)
Completion Status CP
Route of Administration Intramuscular (NCIT IM)
Administration Site Left Deltoid (HL7 LD)

Notes to Testers

No Note

1.1.9. Enter Hib Doses 1-4 of 4

Test Step Type: SUT_MANUAL
Patient History for Hib is entered into the EMR.

Test Story

Description

The EHR vendor loads Hib immunization history data  for Juana Mariana Gonzales.

Comments

No Comments

PreCondition

The EMR has recorded all of the pediatric demographic in the record created for Juana Mariana Gonzales.

PostCondition

The immunization history for Hib known to the local practice is loaded into the record created for Juana Mariana Gonzales.

Test Objectives

Record Past Immunizations: The EHR or other clinical software system allows providers to enter information about immunizations given elsewhere (e.g., by another doctor, at a public health clinic, pharmacy, etc.) with incomplete details.

Evaluation Criteria

Evaluation Criteria: Vendor successfully records all immunization data known to the local practice as provided, with all required attributes indicated by [Y]:

Hib Dose 1 of 4    
Entered BY Sandra Molina Y
Ordering Provider Carlos Herrera Y
Entering Organization Shoreline Pediatrics Y
Administration Notes (Vaccine Event information source) Historical Immunization (NIP001 01) Y
Date/Time of Start of Administration 1/22/2010 Y
Vaccine Administered Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)
PedvaxHIB (NDC 00006-4897-00)		 Y
Administered Amount (of Vaccine) 0.5 Y
Administered Units (of Measure) mL Y
Administering Provider Y
Administered-at Location 333 Oceanview Lane, Stamford Connecticut 06901 Y
Lot Number 7M54K9245 Y
Substance Expiration Date 3/24/2010 Y
Substance Manufacturer Name Merck Sharp & Dohme Corp (MVX MSD) Y
Completion Status CP Y
Route of Administration Intramuscular (NCIT C28161, HL70162: IM) Y
Administration Site Right Thigh (HL7 RT) Y
     
Hib Dose 2 of 4    
Entered BY Sandra Molina Y
Ordering Provider Carlos Herrera Y
Entering Organization Shoreline Pediatrics Y
Vaccine Event information source Historical Immunization (NIP001 01) Y
Value/Text for Vaccine Type  Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)
PedvaxHIB (NDC 00006-4897-00)		 Y
Date/Time of Start of Administration 3/23/2010 Y
Vaccine Administered Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)
PedvaxHIB (NDC 00006-4897-00)
ENGERIX-B (NDC 58160-0820-11)		 Y
Administered Amount (of Vaccine) 0.5 Y
Administered Units (of Measure) mL Y
Administering Provider
J. Martinez Y
Administered-at Location
333 Oceanview Lane, Stamford Connecticut 06901
Y
Lot Number 7M55K3342 Y
Substance Expiration Date 10/30/2010 Y
Substance Manufacturer Name Merck Sharp & Dohme Corp (MVX MSD) Y
Completion Status CP Y
Route of Administration Intramuscular (NCIT IM) Y
Administration Site Left Thigh (HL7 LT)  
     
Hib Dose 3 of 4  
Entered BY Sandra Molina
Ordering Provider Carlos Herrera
Entering Organization Shoreline Pediatrics
Vaccine Event information source Historical Immunization (NIP001 01)
Value/Text for Vaccine Type  Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)
PedvaxHIB (NDC 00006-4897-00)
Date/Time of Start of Administration 5/22/2010
Vaccine Administered Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)
PedvaxHIB (NDC 00006-4897-00)
ENGERIX-B (NDC 58160-0820-11)
Administered Amount (of Vaccine) 0.5
Administered Units (of Measure) mL
Administering Provider
J. Martinez
Administered-at Location
333 Oceanview Lane, Stamford Connecticut 06901
Lot Number 7M75K4566
Substance Expiration Date 5/23/2010
Substance Manufacturer Name Merck Sharp & Dohme Corp (MVX MSD)
Completion Status CP
Route of Administration Intramuscular (NCIT IM)
Administration Site RightThigh (HL7 RT)
Hib Dose 4 of 4  
Entered BY Sandra Molina
Ordering Provider Carlos Herrera
Entering Organization Shoreline Pediatrics
Vaccine Event information source Historical Immunization (NIP001 01)
Value/Text for Vaccine Type  Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)
PedvaxHIB (NDC 00006-4897-00)
Date/Time of Start of Administration 2/21/2011
Vaccine Administered Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)
PedvaxHIB (NDC 00006-4897-00)
Administered Amount (of Vaccine) 0.5
Administered Units (of Measure) mL
Administering Provider
J. Martinez
Administered-at Location
333 Oceanview Lane, Stamford Connecticut 06901
Lot Number 7M53K5534
Substance Expiration Date 2/22/2011
Substance Manufacturer Name Merck Sharp & Dohme Corp (MVX MSD)
Completion Status CP
Route of Administration Intramuscular (NCIT IM)
Administration Site Left Deltoid (HL7 LD)

Notes to Testers

No Note

1.1.10. Enter Polio Dose1 and 2 of 4

Test Step Type: SUT_MANUAL
Patient History for Polio is entered into the EMR.

Test Story

Description

The EHR vendor loads Polio immunization history data  for Juana Mariana Gonzales.

Comments

No Comments

PreCondition

The EMR has recorded all of the pediatric demographic in the record created for Juana Mariana Gonzales.

PostCondition

The immunization history for Polio known to the local practice is loaded into the record created for Juana Mariana Gonzales.

Test Objectives

Record Past Immunizations: The EHR or other clinical software system allows providers to enter information about immunizations given elsewhere (e.g., by another doctor, at a public health clinic, pharmacy, etc.) with incomplete details.

Evaluation Criteria

Evaluation Criteria: Vendor successfully records all immunization data known to the local practice as provided, with all required attributes indicated by [Y]:

Polio Dose 1 of 2    
Entered BY Sandra Molina Y
Ordering Provider Jane Carter Y
Entering Organization Shoreline Pediatrics Y
Administration Notes (Vaccine Event information source) Historical Immunization (NIP001 01) Y
Date/Time of Start of Administration 1/22/2010 Y
Vaccine Administered poliovirus vaccine, inactivated (CVX 10)
IPOL (NDC 49281-0860-55)		 Y
Administered Amount (of Vaccine) 0.5 Y
Administered Units (of Measure) mL Y
Administering Provider Jane Carter Y
Administered-at Location 325 Shorline Drive,  Stamford Connecticut 06901 Y
Lot Number D333PV2431 Y
Substance Expiration Date 10/4/2010 Y
Substance Manufacturer Name Sanofi Pasteur Inc (MVX PMC) Y
Completion Status CP Y
Route of Administration Subcutaneous (NCIT C38299, HL70162: SC) Y
Administration Site Left Deltoid (HL7 LD) Y
     
Polio Dose 2 of 2    
Entered BY Sandra Molina Y
Ordering Provider Carlos Herrera Y
Entering Organization Shoreline Pediatrics Y
Vaccine Event information source Historical Immunization (NIP001 01) Y
Value/Text for Vaccine Type  poliovirus vaccine, inactivated (CVX 10) Y
Date/Time of Start of Administration 3/23/2010 Y
Vaccine Administered poliovirus vaccine, inactivated (CVX 10)
IPOL (NDC 49281-0860-55)		 Y
Administered Amount (of Vaccine) 0.5 Y
Administered Units (of Measure) mL Y
Administering Provider
J. Martinez Y
Administered-at Location
333 Oceanview Lane, Stamford Connecticut 06901
Y
Lot Number D333PV4344 Y
Substance Expiration Date 3/23/2010 Y
Substance Manufacturer Name Sanofi Pasteur Inc (MVX PMC) Y
Completion Status CP Y
Route of Administration Subcutaneous (NCIT C38299, HL70162: SC) Y
Administration Site Left Deltoid (HL7 LD)  

Notes to Testers

No Note

1.1.11. Enter Pneumococcal,Doses 1-4 of 4

Test Step Type: SUT_MANUAL
Patient History for Pneumococcal is entered into the EMR.

Test Story

Description

The EHR vendor loads Pneumococcal immunization history data  for Juana Mariana Gonzales.

Comments

No Comments

PreCondition

The EMR has recorded all of the pediatric demographic in the record created for Juana Mariana Gonzales.

PostCondition

The immunization history for Pneumococcal known to the local practice is loaded into the record created for Juana Mariana Gonzales.

Test Objectives

Record Past Immunizations: The EHR or other clinical software system allows providers to enter information about immunizations given elsewhere (e.g., by another doctor, at a public health clinic, pharmacy, etc.) with incomplete details.

Evaluation Criteria

Evaluation Criteria: Vendor successfully records all immunization data known to the local practice as provided, with all required attributes indicated by [Y]:

Pneumococcal Dose 1 of 4    
Entered BY Sandra Molina Y
Ordering Provider Carlos Herrera Y
Entering Organization Shoreline Pediatrics Y
Administration Notes (Vaccine Event information source) Historical Immunization (NIP001 01) Y
Date/Time of Start of Administration 1/22/2010 Y
Vaccine Administered pneumococcal conjugate vaccine, 13 valent (CVX 133)
PREVNAR 13 (NDC 00005-1971-05)		 Y
Administered Amount (of Vaccine) 0.5 Y
Administered Units (of Measure) mL Y
Administering Provider Y
Administered-at Location 333 Oceanview Lane, Stamford Connecticut 06901 Y
Lot Number P243V3281 Y
Substance Expiration Date 1/30/2010 Y
Substance Manufacturer Name Pfizer, Inc (MVX PFR) Y
Completion Status CP Y
Route of Administration Intramuscular (NCIT C28161, HL70162: IM) Y
Administration Site Left Thigh (HL7 LT) Y
     
Pneumococcal Dose 2 of 4    
Entered BY Sandra Molina Y
Ordering Provider Carlos Herrera Y
Entering Organization Shoreline Pediatrics Y
Vaccine Event information source Historical Immunization (NIP001 01) Y
Value/Text for Vaccine Type  pneumococcal conjugate vaccine, 13 valent (CVX 133) Y
Date/Time of Start of Administration 3/23/2010 Y
Vaccine Administered pneumococcal conjugate vaccine, 13 valent (CVX 133)
PREVNAR 13 (NDC 00005-1971-05)		 Y
Administered Amount (of Vaccine) 0.5 Y
Administered Units (of Measure) mL Y
Administering Provider
J. Martinez Y
Administered-at Location
333 Oceanview Lane, Stamford Connecticut 06901
Y
Lot Number P343V8321 Y
Substance Expiration Date 3/30/2010 Y
Substance Manufacturer Name Pfizer, Inc (MVX PFR) Y
Completion Status CP Y
Route of Administration Intramuscular (NCIT IM) Y
Administration Site Left Thigh (HL7 LT)  
     
Pneumococcal Dose 3 of 4  
Entered BY Sandra Molina
Ordering Provider Carlos Herrera
Entering Organization Shoreline Pediatrics
Vaccine Event information source Historical Immunization (NIP001 01)
Value/Text for Vaccine Type  pneumococcal conjugate vaccine, 13 valent (CVX 133)
Date/Time of Start of Administration 5/22/2010
Vaccine Administered pneumococcal conjugate vaccine, 13 valent (CVX 133)
PREVNAR 13 (NDC 00005-1971-05)
Administered Amount (of Vaccine) 0.5
Administered Units (of Measure) mL
Administering Provider
J. Martinez
Administered-at Location
333 Oceanview Lane, Stamford Connecticut 06901
Lot Number P853V2164
Substance Expiration Date 8/30/2010
Substance Manufacturer Name Pfizer, Inc (MVX PFR)
Completion Status CP
Route of Administration Intramuscular (NCIT IM)
Administration Site RightThigh (HL7 RT)
Pneumococcal Dose 4 of 4  
Entered BY Sandra Molina
Ordering Provider Carlos Herrera
Entering Organization Shoreline Pediatrics
Vaccine Event information source Historical Immunization (NIP001 01)
Value/Text for Vaccine Type  pneumococcal conjugate vaccine, 13 valent (CVX 133)
Date/Time of Start of Administration 2/21/2011
Vaccine Administered pneumococcal conjugate vaccine, 13 valent (CVX 133)
PREVNAR 13 (NDC 00005-1971-05)
Administered Amount (of Vaccine) 0.5
Administered Units (of Measure) mL
Administering Provider
J. Martinez
Administered-at Location
333 Oceanview Lane, Stamford Connecticut 06901
Lot Number P853V58532
Substance Expiration Date 4/18/2011
Substance Manufacturer Name Pfizer, Inc (MVX PFR)
Completion Status CP
Route of Administration Intramuscular (NCIT IM)
Administration Site Left Deltoid (HL7 LD)

Notes to Testers

No Note

1.1.12. Enter Rotavirus Dose1 and 2 of 3

Test Step Type: SUT_MANUAL
Patient History for Rotavirus is entered into the EMR.

Test Story

Description

The EHR vendor loads Rotavirus immunization history data  for Juana Mariana Gonzales.

Comments

No Comments

PreCondition

The EMR has recorded all of the pediatric demographic in the record created for Juana Mariana Gonzales.

PostCondition

The immunization history for Rotavirus known to the local practice is loaded into the record created for Juana Mariana Gonzales.

Test Objectives

Record Past Immunizations: The EHR or other clinical software system allows providers to enter information about immunizations given elsewhere (e.g., by another doctor, at a public health clinic, pharmacy, etc.) with incomplete details.

Evaluation Criteria

Evaluation Criteria: Vendor successfully records all immunization data known to the local practice as provided, with all required attributes indicated by [Y]:

Rotavirus Dose 1 of 3    
Entered BY Sandra Molina Y
Ordering Provider Jane Carter Y
Entering Organization Shoreline Pediatrics Y
Administration Notes (Vaccine Event information source) Historical Immunization (NIP001 01) Y
Date/Time of Start of Administration 1/22/2010 Y
Vaccine Administered rotavirus, live, monovalent vaccine (CVX 119)
ROTARIX (NDC 58160-0854-52)		 Y
Administered Amount (of Vaccine) 0.5 Y
Administered Units (of Measure) mL Y
Administering Provider Jane Carter Y
Administered-at Location 325 Shorline Drive,  Stamford Connecticut 06901 Y
Lot Number 6359RV533 Y
Substance Expiration Date 2/15/2010 Y
Substance Manufacturer Name GlaxoSmithKline Biologicals SA (MVX SKB) Y
Completion Status CP Y
Route of Administration Intramuscular (NCIT C28161, HL70162: IM) Y
Administration Site Left Thigh (HL7 LT) Y
     
Rotavirus Dose 2 of 3    
Entered BY Sandra Molina Y
Ordering Provider Carlos Herrera Y
Entering Organization Shoreline Pediatrics Y
Vaccine Event information source Historical Immunization (NIP001 01) Y
Value/Text for Vaccine Type  rotavirus, live, monovalent vaccine (CVX 119) Y
Date/Time of Start of Administration 3/23/2010 Y
Vaccine Administered rotavirus, live, monovalent vaccine (CVX 119)
ROTARIX (NDC 58160-0854-52)		 Y
Administered Amount (of Vaccine) 0.5 Y
Administered Units (of Measure) mL Y
Administering Provider
J. Martinez Y
Administered-at Location
333 Oceanview Lane, Stamford Connecticut 06901
Y
Lot Number 6359RV932 Y
Substance Expiration Date 5/10/2011 Y
Substance Manufacturer Name GlaxoSmithKline Biologicals SA (MVX SKB) Y
Completion Status CP Y
Route of Administration Intramuscular (NCIT IM) Y
Administration Site Right Thigh (HL7 RT)  

Notes to Testers

No Note

1.1.13. Enter Influenza History Doses

Test Step Type: SUT_MANUAL
Patient History for Influenza is entered into the EMR.

Test Story

Description

The EHR vendor loads Influenza immunization history data  for Juana Mariana Gonzales.

Comments

No Comments

PreCondition

The EMR has recorded all of the pediatric demographic in the record created for Juana Mariana Gonzales.

PostCondition

The immunization history for Influenza known to the local practice is loaded into the record created for Juana Mariana Gonzales.

Test Objectives

Record Past Immunizations: The EHR or other clinical software system allows providers to enter information about immunizations given elsewhere (e.g., by another doctor, at a public health clinic, pharmacy, etc.) with incomplete details.

Evaluation Criteria

Evaluation Criteria: Vendor successfully records all immunization data known to the local practice as provided, with all required attributes indicated by [Y]:

Influenza Dose 1 of 2    
Entered BY Sandra Molina Y
Ordering Provider Carlos Herrera Y
Entering Organization Shoreline Pediatrics Y
Administration Notes (Vaccine Event information source) Historical Immunization (NIP001 01) Y
Date/Time of Start of Administration 9/25/2010 Y
Vaccine Administered Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161)
FLUZONE QUADRIVALENT (NDC 49281-0514-25)		 Y
Administered Amount (of Vaccine) 0.25 Y
Administered Units (of Measure) mL Y
Administering Provider Y
Administered-at Location 333 Oceanview Lane, Stamford Connecticut 06901 Y
Lot Number D8043IN8734 Y
Substance Expiration Date 3/12/2011 Y
Substance Manufacturer Name Sanofi Pasteur Inc (MVX PMC) Y
Completion Status CP Y
Route of Administration Intramuscular (NCIT C28161, HL70162: IM) Y
Administration Site Left Thigh (HL7 LT) Y
     
Influenza Dose 2 of 2    
Entered BY Sandra Molina Y
Ordering Provider Carlos Herrera Y
Entering Organization Shoreline Pediatrics Y
Vaccine Event information source Historical Immunization (NIP001 01) Y
Value/Text for Vaccine Type  Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) Y
Date/Time of Start of Administration 10/27/2010 Y
Vaccine Administered Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161)
FLUZONE QUADRIVALENT (NDC 49281-0514-25)		 Y
Administered Amount (of Vaccine) 0.25 Y
Administered Units (of Measure) mL Y
Administering Provider
J. Martinez Y
Administered-at Location
333 Oceanview Lane, Stamford Connecticut 06901
Y
Lot Number D8043IN8734 Y
Substance Expiration Date 3/12/2011 Y
Substance Manufacturer Name Sanofi Pasteur Inc (MVX PMC) Y
Completion Status CP Y
Route of Administration Intramuscular (NCIT IM) Y
Administration Site Right Thigh (HL7 RT)  
     
Influenza Annual Dose  
Entered BY Sandra Molina
Ordering Provider Carlos Herrera
Entering Organization Shoreline Pediatrics
Vaccine Event information source Historical Immunization (NIP001 01)
Value/Text for Vaccine Type  Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161)
Date/Time of Start of Administration 10/2/2011
Vaccine Administered Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161)
FLUZONE QUADRIVALENT (NDC 49281-0514-25)
Administered Amount (of Vaccine) 0.25
Administered Units (of Measure) mL
Administering Provider
J. Martinez
Administered-at Location
333 Oceanview Lane, Stamford Connecticut 06901
Lot Number D9334IN9333
Substance Expiration Date 5/22/2012
Substance Manufacturer Name Sanofi Pasteur Inc (MVX PMC)
Completion Status CP
Route of Administration Intramuscular (NCIT IM)
Administration Site Left Deltoid (HL7 LD)
Influenza Annual Dose  
Entered BY Sandra Molina
Ordering Provider Carlos Herrera
Entering Organization Shoreline Pediatrics
Vaccine Event information source Historical Immunization (NIP001 01)
Value/Text for Vaccine Type  Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161)
Date/Time of Start of Administration 2/21/2011
Vaccine Administered Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161)
FLUZONE QUADRIVALENT (NDC 49281-0514-25)
Administered Amount (of Vaccine) 0.25
Administered Units (of Measure) mL
Administering Provider
J. Martinez
Administered-at Location
333 Oceanview Lane, Stamford Connecticut 06901
Lot Number D9553IN2243
Substance Expiration Date 4/30/2012
Substance Manufacturer Name Sanofi Pasteur Inc (MVX PMC)
Completion Status CP
Route of Administration Intramuscular (NCIT IM)
Administration Site Left Deltoid (HL7 LD)

Notes to Testers

No Note

1.1.14. Enter HepA Dose1 and 2 of 2

Test Step Type: SUT_MANUAL
Patient History for HepA is entered into the EMR.

Test Story

Description

The EHR vendor loads HepA immunization history data  for Juana Mariana Gonzales.

Comments

No Comments

PreCondition

The EMR has recorded all of the pediatric demographic in the record created for Juana Mariana Gonzales.

PostCondition

The immunization history for HepA known to the local practice is loaded into the record created for Juana Mariana Gonzales.

Test Objectives

Record Past Immunizations: The EHR or other clinical software system allows providers to enter information about immunizations given elsewhere (e.g., by another doctor, at a public health clinic, pharmacy, etc.) with incomplete details.

Evaluation Criteria

Evaluation Criteria: Vendor successfully records all immunization data known to the local practice as provided, with all required attributes indicated by [Y]:

HepA Dose 1 of 2    
Entered BY Sandra Molina Y
Ordering Provider Jane Carter Y
Entering Organization Shoreline Pediatrics Y
Administration Notes (Vaccine Event information source) Historical Immunization (NIP001 01) Y
Date/Time of Start of Administration 11/23/2011 Y
Vaccine Administered hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule (CVX 83)
HAVRIX (NDC 58160-0825-52)		 Y
Administered Amount (of Vaccine) 0.5 Y
Administered Units (of Measure) mL Y
Administering Provider Jane Carter Y
Administered-at Location 325 Shorline Drive,  Stamford Connecticut 06901 Y
Lot Number 6359RT33 Y
Substance Expiration Date 1/4/2012 Y
Substance Manufacturer Name GlaxoSmithKline Biologicals SA (MVX SKB) Y
Completion Status CP Y
Route of Administration Intramuscular (NCIT C28161, HL70162: IM) Y
Administration Site Right Deltoid (HL7 RD) Y
     
HepA Dose 2 of 2    
Entered BY Sandra Molina Y
Ordering Provider Carlos Herrera Y
Entering Organization Shoreline Pediatrics Y
Vaccine Event information source Historical Immunization (NIP001 01) Y
Value/Text for Vaccine Type  hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule (CVX 83) Y
Date/Time of Start of Administration 5/23/2012 Y
Vaccine Administered hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule (CVX 83)
HAVRIX (NDC 58160-0825-52)		 Y
Administered Amount (of Vaccine) 0.5 Y
Administered Units (of Measure) mL Y
Administering Provider
J. Martinez Y
Administered-at Location
333 Oceanview Lane, Stamford Connecticut 06901
Y
Lot Number 6359RT48 Y
Substance Expiration Date 9/11/2012 Y
Substance Manufacturer Name GlaxoSmithKline Biologicals SA (MVX SKB) Y
Completion Status CP Y
Route of Administration Intramuscular (NCIT C28161, HL70162: IM) Y
Administration Site Left Deltoid (HL7 LD)  

Notes to Testers

No Note

1.1.15. Enter MMRV Dose1 and 2 of 3

Test Step Type: SUT_MANUAL
Patient History for MMRV is entered into the EMR.

Test Story

Description

The EHR vendor loads MMRV immunization history data  for Juana Mariana Gonzales.

Comments

The first dose is administered too early and will be invalid for the dose series

PreCondition

The EMR has recorded all of the pediatric demographic in the record created for Juana Mariana Gonzales.

PostCondition

The immunization history for MMRV known to the local practice is loaded into the record created for Juana Mariana Gonzales.

Test Objectives

Record Past Immunizations: The EHR or other clinical software system allows providers to enter information about immunizations given elsewhere (e.g., by another doctor, at a public health clinic, pharmacy, etc.) with incomplete details.

Evaluation Criteria

Evaluation Criteria: Vendor successfully records all immunization data known to the local practice as provided, with all required attributes indicated by [Y]:

MMRV Dose 1 of 3 [dose is invalid]    
Entered BY Sandra Molina Y
Ordering Provider Jane Carter Y
Entering Organization Shoreline Pediatrics Y
Administration Notes (Vaccine Event information source) Historical Immunization (NIP001 01) Y
Date/Time of Start of Administration 10/23/2010 Y
Vaccine Administered measles, mumps, rubella, and varicella virus vaccine (CVX 94)
ProQuad (NDC 00006-4999-00)		 Y
Administered Amount (of Vaccine) 0.5 Y
Administered Units (of Measure) mL Y
Administering Provider Jane Carter Y
Administered-at Location 325 Shorline Drive,  Stamford Connecticut 06901 Y
Lot Number 7W27V7491 Y
Substance Expiration Date 12/15/2010 Y
Substance Manufacturer Name Merck Sharp & Dohme Corp (MVX MSD) Y
Completion Status CP Y
Route of Administration Subcutaneous (NCIT C38299, HL70162: SC) Y
Administration Site Left Thigh (HL7 LT) Y
     
MMRV Dose 2 of 3 [first dose is invalid]    
Entered BY Sandra Molina Y
Ordering Provider Carlos Herrera Y
Entering Organization Shoreline Pediatrics Y
Vaccine Event information source Historical Immunization (NIP001 01) Y
Value/Text for Vaccine Type  measles, mumps, rubella, and varicella virus vaccine (CVX 94) Y
Date/Time of Start of Administration 11/22/2012 Y
Vaccine Administered measles, mumps, rubella, and varicella virus vaccine (CVX 94)
ProQuad (NDC 00006-4999-00)		 Y
Administered Amount (of Vaccine) 0.5 Y
Administered Units (of Measure) mL Y
Administering Provider
J. Martinez Y
Administered-at Location
333 Oceanview Lane, Stamford Connecticut 06901
Y
Lot Number 7W87V3452 Y
Substance Expiration Date 4/13/2013 Y
Substance Manufacturer Name Merck Sharp & Dohme Corp (MVX MSD) Y
Completion Status CP Y
Route of Administration Subcutaneous (NCIT C38299, HL70162: SC) Y
Administration Site Left Deltoid (HL7 LD)  

Notes to Testers

No Note

1.2. Juan Marcel Gonzales Initial Data Load

Demonstrates the ability to record pediatric demographic data, historical vaccinations, and clinical conditions for 3 1/2-year old Juan Marcel Gonzales. There are no transactions associated with this test case.

Test Story

Description
No Description

Comments
No Comments

PreCondition
No PreCondition

PostCondition
No PostCondition

Test Objectives
No Test Objectives

Evaluation Criteria
No evaluation criteria

Notes to Testers
No Note

1.2.1. Enter Initial Demographic Data for New Patient Juan Marcel Gonzales

Test Step Type: SUT_MANUAL
Juan Marcel Gonzales is entered as a patient in the EMR, including all pediatric demographic information.

Test Story

Description

The EHR vendor loads demographic data for Juan Marcel Gonzales.

Comments

Set-up step evaluating EMR functions for capturing and storing patient pediatric demographic data. There is no transaction associated with this test step.

PreCondition

No PreCondition

PostCondition

The EMR has recorded all of the pediatric demographic  in the record created for Juan Marcel Gonzales.

Test Objectives

Register New Patients: The system must allow a user to enter distinguishing information about patients so that providers can uniquely identify patients who have similar sounding names or other similar identifying information.  For example, twins living in the same household will have similar dates of birth, addresses, and may have similar names. EHRs or other clinical software must be able to store information to successfully match with patients in immunization registries, if the information is available. The information includes the mother’s maiden name, whether the patient was part of a multiple birth, and the order of the multiple birth. This information allows the provider to correctly identify the patient and also helps assure a match when the EHR send the patient’s information to external systems such as an immunization registry.

Evaluation Criteria

Evaluation Criteria: Vendor successfully records all demographic data provided, and in particular (Mother's maiden name, multiple birth, birth order), with all required attributes indicated by [Y]:

Patient ID (previously listed as “Medicaid Number”)

Vendor supplied

Y

Patient ID: Assigning Authority ID (i.e., owning source)/Facility Name

Shoreline Pediatrics

Y

Patient ID: Type (e.g., medical record number, IIS ID)

Vendor supplied

Y

Patient Name: First 

Juan

Y

Patient Name: Middle

Marcel

Y

Patient Name: Last

Gonzales

Y

Patient Date of Birth

11/23/2011

Y

Birth Time

11 am

N

Patient Gender (Administrative Sex)

M

Y

Patient Multiple Birth Indicator

N

Y

Patient Birth Order

NA

C

Responsible Person Name: First

Manuel

Y

Responsible Person Name: Middle

Marcel

Y

Responsible Person Name: Last

Gonzales

Y

Responsible Person Name: Relationship to Patient

Father

Y

Mother’s Name: First

Anita

Y

Mother’s Name: Middle

Francesca

Y

Mother’s Name: Last

Gonzales

Y

Mother’s Name: Maiden Last

Morales

Y

Patient Address: Street

4623 Standish Way

Y

Patient Address: City

Stamford

Y

Patient Address: State

CT

Y

Patient Address: Country

USA

Y

Patient Address: Zipcode

06903

Y

Patient Address: County of Residence

Fairfield

N

Race

Other

Y

Ethnicity

Hispanic or Latino

Y

Birthing Facility Name (Birth Delivery Location Address BDL)

Shoreline Hospital
325 Shorline Drive, Stamford Connecticut 06901

[Y – birthing

 facility name,

not address]

Patient Birth State

CT

Y

Patient Primary Language

English

Y

Patient Telephone Number

(203) 555-1213

Y

Patient Telephone Number Type (e.g., home, cell)

Home

Y

Patient E-mail Address

None

N

Publicity Code

  

N

Protection Indicator

  

N

Protection Indicator Effective Date

  

N

Immunization Registry Status

  

N

Preferred Contact Method

Phone

  

Notes to Testers

No Note

1.2.2. Enter Clinical History for Juan Marcel Gonzales

Test Step Type: SUT_MANUAL
The EHR captures structured data regarding a problem of Asthma as part of the clinical history.

Test Story

Description

The clinical history of Moderate Persistent Asthma is documented in the record created for Juan Marcel Gonzales.

Comments

No Comments

PreCondition

The EMR has recorded all of the pediatric demographic  in the record created for Juan Marcel Gonzales.

PostCondition

The clinical history of the Moderate Persistent Asthma is documented in the record created for Juan Marcel Gonzales.

Test Objectives

Supporting data for testing contraindications.

Evaluation Criteria

Evaluation Criteria: Vendor successfully records all clinical history data provided with all required attributes indicated by [Y]:

Adverse History of Asthma      
Problems Moderate Persistent Asthma (e.g. Moderate persistent asthma – SNOMED-CT 427295004) Y Coded value expected using SNOMED-CT or ICD

Notes to Testers

No Note

1.2.3. Enter HepB Dose1 and 2 of 3

Test Step Type: SUT_MANUAL
Patient History for HepB is entered into the EMR for Juan Marcel.

Test Story

Description

The EHR vendor loads HepB immunization history data  for Juan Marcel Gonzales.

Comments

No Comments

PreCondition

The EMR has recorded all of the pediatric demographic in the record created for Juan Marcel Gonzales.

PostCondition

The immunization history for HepB known to the local practice is loaded into the record created for Juan Marcel Gonzales.

Test Objectives

Record Past Immunizations: The EHR or other clinical software system allows providers to enter information about immunizations given elsewhere (e.g., by another doctor, at a public health clinic, pharmacy, etc.) with incomplete details.

Evaluation Criteria

Evaluation Criteria: Vendor successfully records all immunization data known to the local practice as provided, with all required attributes indicated by [Y]:

HepB Dose 1 of 3    
Entered BY Sandra Molina Y
Ordering Provider Jane Carter Y
Entering Organization Shoreline Pediatrics Y
Administration Notes (Vaccine Event information source) Historical Immunization (NIP001 01) Y
Date/Time of Start of Administration 11/23/2011 Y
Vaccine Administered hepatitis B vaccine, pediatric or pediatric/adolescent dosage  (CVX 08) Y
Administered Amount (of Vaccine) 0.5 Y
Administered Units (of Measure) mL Y
Administering Provider Jane Carter Y
Administered-at Location 325 Shorline Drive,  Stamford Connecticut 06901 Y
Lot Number 6332FK34 Y
Substance Expiration Date 12/14/2011 Y
Substance Manufacturer Name GlaxoSmithKline Biologicals SA (MVX SKB) Y
Completion Status CP Y
Route of Administration Intramuscular (NCIT C28161, HL70162: IM) Y
Administration Site Left Thigh (HL7 LT) Y
     
HepB Dose 3 of 3    
Entered BY Sandra Molina Y
Ordering Provider Carlos Herrera Y
Entering Organization Shoreline Pediatrics Y
Vaccine Event information source Historical Immunization (NIP001 01) Y
Value/Text for Vaccine Type  hepatitis B vaccine, pediatric or pediatric/adolescent dosage  (CVX 08) Y
Date/Time of Start of Administration 12/23/2013 Y
Vaccine Administered hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08)
ENGERIX-B (NDC 58160-0820-11)		 Y
Administered Amount (of Vaccine) 0.5 Y
Administered Units (of Measure) mL Y
Administering Provider
J. Martinez Y
Administered-at Location
333 Oceanview Lane, Stamford Connecticut 06901
Y
Lot Number 6352FK2 Y
Substance Expiration Date 1/1/2014 Y
Substance Manufacturer Name GlaxoSmithKline Biologicals SA (MVX SKB) Y
Completion Status CP Y
Route of Administration Intramuscular (NCIT IM) Y
Administration Site Right Thigh (HL7 RT)  

Notes to Testers

No Note

1.2.4. Enter DTaP Doses 1-4 of 5 Juan Marcel

Test Step Type: SUT_MANUAL
Patient History for DTaP is entered into the EMR for Juan Marcel Gonzales.

Test Story

Description

The EHR vendor loads DTaP  immunization history data  for Juan Marcel Gonzales.

Comments

No Comments

PreCondition

The EMR has recorded all of the pediatric demographic in the record created for Juan Marcel Gonzales.

PostCondition

The immunization history for DTaP known to the local practice is loaded into the record created for Juan Marcel Gonzales.

Test Objectives

Record Past Immunizations: The EHR or other clinical software system allows providers to enter information about immunizations given elsewhere (e.g., by another doctor, at a public health clinic, pharmacy, etc.) with incomplete details.

Evaluation Criteria

Evaluation Criteria: Vendor successfully records all immunization data known to the local practice as provided, with all required attributes indicated by [Y]:

DTaP Dose 1 of 5    
Entered BY Sandra Molina Y
Ordering Provider Carlos Herrera Y
Entering Organization Shoreline Pediatrics Y
Administration Notes (Vaccine Event information source) Historical Immunization (NIP001 01) Y
Date/Time of Start of Administration 1/22/2012 Y
Vaccine Administered diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)
DAPTACEL (NDC 49281-0286-01)		 Y
Administered Amount (of Vaccine) 0.5 Y
Administered Units (of Measure) mL Y
Administering Provider Y
Administered-at Location 333 Oceanview Lane, Stamford Connecticut 06901 Y
Lot Number D409QS2342 Y
Substance Expiration Date 11/30/2012 Y
Substance Manufacturer Name Sanofi Pasteur Inc (MVX PMC) Y
Completion Status CP Y
Route of Administration Intramuscular (NCIT C28161, HL70162: IM) Y
Administration Site Left Thigh (HL7 LT) Y
     
DTaP Dose 2 of 5    
Entered BY Sandra Molina Y
Ordering Provider Carlos Herrera Y
Entering Organization Shoreline Pediatrics Y
Vaccine Event information source Historical Immunization (NIP001 01) Y
Value/Text for Vaccine Type  diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)
DAPTACEL (NDC 49281-0286-01)		 Y
Date/Time of Start of Administration 3/22/2012 Y
Vaccine Administered diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)
DAPTACEL (NDC 49281-0286-01)
ENGERIX-B (NDC 58160-0820-11)		 Y
Administered Amount (of Vaccine) 0.5 Y
Administered Units (of Measure) mL Y
Administering Provider
J. Martinez Y
Administered-at Location
333 Oceanview Lane, Stamford Connecticut 06901
Y
Lot Number D409QS2434 Y
Substance Expiration Date 9/4/2012 Y
Substance Manufacturer Name Sanofi Pasteur Inc (MVX PMC) Y
Completion Status CP Y
Route of Administration Intramuscular (NCIT IM) Y
Administration Site Right Thigh (HL7 RT)  
     
DTaP Dose 3 of 5  
Entered BY Sandra Molina
Ordering Provider Carlos Herrera
Entering Organization Shoreline Pediatrics
Vaccine Event information source Historical Immunization (NIP001 01)
Value/Text for Vaccine Type  diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)
DAPTACEL (NDC 49281-0286-01)
Date/Time of Start of Administration 5/21/2012
Vaccine Administered diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)
DAPTACEL (NDC 49281-0286-01)
ENGERIX-B (NDC 58160-0820-11)
Administered Amount (of Vaccine) 0.5
Administered Units (of Measure) mL
Administering Provider
J. Martinez
Administered-at Location
333 Oceanview Lane, Stamford Connecticut 06901
Lot Number D409QS3256
Substance Expiration Date 12/1/2012
Substance Manufacturer Name Sanofi Pasteur Inc (MVX PMC)
Completion Status CP
Route of Administration Intramuscular (NCIT IM)
Administration Site Left Thigh (HL7 LT)
DTaP Dose 4 of 5  
Entered BY Sandra Molina
Ordering Provider Carlos Herrera
Entering Organization Shoreline Pediatrics
Vaccine Event information source Historical Immunization (NIP001 01)
Value/Text for Vaccine Type  diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)
DAPTACEL (NDC 49281-0286-01)
Date/Time of Start of Administration 2/20/2013
Vaccine Administered diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)
DAPTACEL (NDC 49281-0286-01)
ENGERIX-B (NDC 58160-0820-11)
Administered Amount (of Vaccine) 0.5
Administered Units (of Measure) mL
Administering Provider
J. Martinez
Administered-at Location
333 Oceanview Lane, Stamford Connecticut 06901
Lot Number D409QS250
Substance Expiration Date 3/1/2014
Substance Manufacturer Name Sanofi Pasteur Inc (MVX PMC)
Completion Status CP
Route of Administration Intramuscular (NCIT IM)
Administration Site Left Deltoid (HL7 LD)

Notes to Testers

No Note

1.2.5. Enter Hib Doses 1-4 of 4 Juan Marcel

Test Step Type: SUT_MANUAL
Patient History for Hib is entered into the EMR for Juan Marcel Gonzales.

Test Story

Description

The EHR vendor loads Hib immunization history data  for Juan Marcel Gonzales.

Comments

No Comments

PreCondition

The EMR has recorded all of the pediatric demographic in the record created for Juan Macel Gonzales.

PostCondition

The immunization history for Hib known to the local practice is loaded into the record created for Juan Marcel Gonzales.

Test Objectives

Record Past Immunizations: The EHR or other clinical software system allows providers to enter information about immunizations given elsewhere (e.g., by another doctor, at a public health clinic, pharmacy, etc.) with incomplete details.

Evaluation Criteria

Evaluation Criteria: Vendor successfully records all immunization data known to the local practice as provided, with all required attributes:

Hib Dose 1 of 4    
Entered BY Sandra Molina Y
Ordering Provider Carlos Herrera Y
Entering Organization Shoreline Pediatrics Y
Administration Notes (Vaccine Event information source) Historical Immunization (NIP001 01) Y
Date/Time of Start of Administration 1/22/2012 Y
Vaccine Administered Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)
PedvaxHIB (NDC 00006-4897-00)		 Y
Administered Amount (of Vaccine) 0.5 Y
Administered Units (of Measure) mL Y
Administering Provider Y
Administered-at Location 333 Oceanview Lane, Stamford Connecticut 06901 Y
Lot Number 7M54K9255 Y
Substance Expiration Date 3/24/2012 Y
Substance Manufacturer Name Merck Sharp & Dohme Corp (MVX MSD) Y
Completion Status CP Y
Route of Administration Intramuscular (NCIT C28161, HL70162: IM) Y
Administration Site Right Thigh (HL7 RT) Y
     
Hib Dose 2 of 4    
Entered BY Sandra Molina Y
Ordering Provider Carlos Herrera Y
Entering Organization Shoreline Pediatrics Y
Vaccine Event information source Historical Immunization (NIP001 01) Y
Value/Text for Vaccine Type  Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)
PedvaxHIB (NDC 00006-4897-00)		 Y
Date/Time of Start of Administration 3/22/2012 Y
Vaccine Administered Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)
PedvaxHIB (NDC 00006-4897-00)
ENGERIX-B (NDC 58160-0820-11)		 Y
Administered Amount (of Vaccine) 0.5 Y
Administered Units (of Measure) mL Y
Administering Provider
J. Martinez Y
Administered-at Location
333 Oceanview Lane, Stamford Connecticut 06901
Y
Lot Number 7M55K3343 Y
Substance Expiration Date 10/30/2012 Y
Substance Manufacturer Name Merck Sharp & Dohme Corp (MVX MSD) Y
Completion Status CP Y
Route of Administration Intramuscular (NCIT IM) Y
Administration Site Left Thigh (HL7 LT)  
     
Hib Dose 3 of 4  
Entered BY Sandra Molina
Ordering Provider Carlos Herrera
Entering Organization Shoreline Pediatrics
Vaccine Event information source Historical Immunization (NIP001 01)
Value/Text for Vaccine Type  Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)
PedvaxHIB (NDC 00006-4897-00)
Date/Time of Start of Administration 5/21/2012
Vaccine Administered Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)
PedvaxHIB (NDC 00006-4897-00)
ENGERIX-B (NDC 58160-0820-11)
Administered Amount (of Vaccine) 0.5
Administered Units (of Measure) mL
Administering Provider
J. Martinez
Administered-at Location
333 Oceanview Lane, Stamford Connecticut 06901
Lot Number 7M75K4577
Substance Expiration Date 5/23/2012
Substance Manufacturer Name Merck Sharp & Dohme Corp (MVX MSD)
Completion Status CP
Route of Administration Intramuscular (NCIT IM)
Administration Site RightThigh (HL7 RT)
Hib Dose 4 of 4  
Entered BY Sandra Molina
Ordering Provider Carlos Herrera
Entering Organization Shoreline Pediatrics
Vaccine Event information source Historical Immunization (NIP001 01)
Value/Text for Vaccine Type  Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)
PedvaxHIB (NDC 00006-4897-00)
Date/Time of Start of Administration 11/22/2012
Vaccine Administered Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)
PedvaxHIB (NDC 00006-4897-00)
Administered Amount (of Vaccine) 0.5
Administered Units (of Measure) mL
Administering Provider
J. Martinez
Administered-at Location
333 Oceanview Lane, Stamford Connecticut 06901
Lot Number 7M53K5535
Substance Expiration Date 2/22/2012
Substance Manufacturer Name Merck Sharp & Dohme Corp (MVX MSD)
Completion Status CP
Route of Administration Intramuscular (NCIT IM)
Administration Site Left Deltoid (HL7 LD)

Notes to Testers

No Note

1.2.6. Enter Polio Dose1-3 of 4 Juan Marcel

Test Step Type: SUT_MANUAL
Patient History for Polio is entered into the EMR for Juan Marcel Gonzales.

Test Story

Description

The EHR vendor loads Polio immunization history data  for Juan Marcel Gonzales.

Comments

No Comments

PreCondition

The EMR has recorded all of the pediatric demographic in the record created for Juan Marcel Gonzales.

PostCondition

The immunization history for Polio known to the local practice is loaded into the record created for Juan Marcel Gonzales.

Test Objectives

Record Past Immunizations: The EHR or other clinical software system allows providers to enter information about immunizations given elsewhere (e.g., by another doctor, at a public health clinic, pharmacy, etc.) with incomplete details.

Evaluation Criteria

Evaluation Criteria: Vendor successfully records all immunization data known to the local practice as provided, with all required attributes indicated by [Y]:

Polio Dose 1 of 4    
Entered BY Sandra Molina Y
Ordering Provider Jane Carter Y
Entering Organization Shoreline Pediatrics Y
Administration Notes (Vaccine Event information source) Historical Immunization (NIP001 01) Y
Date/Time of Start of Administration 1/22/2012 Y
Vaccine Administered poliovirus vaccine, inactivated (CVX 10)
IPOL (NDC 49281-0860-55)		 Y
Administered Amount (of Vaccine) 0.5 Y
Administered Units (of Measure) mL Y
Administering Provider Jane Carter Y
Administered-at Location 325 Shorline Drive,  Stamford Connecticut 06901 Y
Lot Number D333PV2444 Y
Substance Expiration Date 10/4/2012 Y
Substance Manufacturer Name Sanofi Pasteur Inc (MVX PMC) Y
Completion Status CP Y
Route of Administration Subcutaneous (NCIT C38299, HL70162: SC) Y
Administration Site Left Deltoid (HL7 LD) Y
     
Polio Dose 2 of 4    
Entered BY Sandra Molina Y
Ordering Provider Carlos Herrera Y
Entering Organization Shoreline Pediatrics Y
Vaccine Event information source Historical Immunization (NIP001 01) Y
Value/Text for Vaccine Type  poliovirus vaccine, inactivated (CVX 10) Y
Date/Time of Start of Administration 3/22/2012 Y
Vaccine Administered poliovirus vaccine, inactivated (CVX 10)
IPOL (NDC 49281-0860-55)		 Y
Administered Amount (of Vaccine) 0.5 Y
Administered Units (of Measure) mL Y
Administering Provider
J. Martinez Y
Administered-at Location
333 Oceanview Lane, Stamford Connecticut 06901
Y
Lot Number D333PV4343 Y
Substance Expiration Date 3/23/2012 Y
Substance Manufacturer Name Sanofi Pasteur Inc (MVX PMC) Y
Completion Status CP Y
Route of Administration Subcutaneous (NCIT C38299, HL70162: SC) Y
Administration Site Left Deltoid (HL7 LD)  
Polio Dose 3 of 4  
Entered BY Sandra Molina
Ordering Provider Carlos Herrera
Entering Organization Shoreline Pediatrics
Vaccine Event information source Historical Immunization (NIP001 01)
Value/Text for Vaccine Type  poliovirus vaccine, inactivated (CVX 10)
Date/Time of Start of Administration 5/21/2012
Vaccine Administered poliovirus vaccine, inactivated (CVX 10)
IPOL (NDC 49281-0860-55)
Administered Amount (of Vaccine) 0.5
Administered Units (of Measure) mL
Administering Provider
J. Martinez
Administered-at Location
333 Oceanview Lane, Stamford Connecticut 06901
Lot Number D335PV9654
Substance Expiration Date 2/22/2013
Substance Manufacturer Name Sanofi Pasteur Inc (MVX PMC)
Completion Status CP
Route of Administration Subcutaneous (NCIT C38299, HL70162: SC)
Administration Site Left Deltoid (HL7 LD)

 

Notes to Testers

No Note

1.2.7. Enter Pneumococcal,Doses 1-4 of 4 Juan Marcel

Test Step Type: SUT_MANUAL
Patient History for Pneumococcal is entered into the EMR for Juan Marcel Gonzales.

Test Story

Description

The EHR vendor loads Pneumococcal immunization history data  for Juan Marcel Gonzales.

Comments

No Comments

PreCondition

The EMR has recorded all of the pediatric demographic in the record created for Juan Marcel Gonzales.

PostCondition

The immunization history for Pneumococcal known to the local practice is loaded into the record created for Juan Marcel Gonzales.

Test Objectives

Record Past Immunizations: The EHR or other clinical software system allows providers to enter information about immunizations given elsewhere (e.g., by another doctor, at a public health clinic, pharmacy, etc.) with incomplete details.

Evaluation Criteria

Evaluation Criteria: Vendor successfully records all immunization data known to the local practice as provided, with all required attributes indicated by [Y]:

Pneumococcal Dose 1 of 4    
Entered BY Sandra Molina Y
Ordering Provider Carlos Herrera Y
Entering Organization Shoreline Pediatrics Y
Administration Notes (Vaccine Event information source) Historical Immunization (NIP001 01) Y
Date/Time of Start of Administration 1/22/2012 Y
Vaccine Administered pneumococcal conjugate vaccine, 13 valent (CVX 133)
PREVNAR 13 (NDC 00005-1971-05)		 Y
Administered Amount (of Vaccine) 0.5 Y
Administered Units (of Measure) mL Y
Administering Provider Y
Administered-at Location 333 Oceanview Lane, Stamford Connecticut 06901 Y
Lot Number P243V3321 Y
Substance Expiration Date 1/30/2012 Y
Substance Manufacturer Name Pfizer, Inc (MVX PFR) Y
Completion Status CP Y
Route of Administration Intramuscular (NCIT C28161, HL70162: IM) Y
Administration Site Left Thigh (HL7 LT) Y
     
Pneumococcal Dose 2 of 4    
Entered BY Sandra Molina Y
Ordering Provider Carlos Herrera Y
Entering Organization Shoreline Pediatrics Y
Vaccine Event information source Historical Immunization (NIP001 01) Y
Value/Text for Vaccine Type  pneumococcal conjugate vaccine, 13 valent (CVX 133) Y
Date/Time of Start of Administration 3/22/2012 Y
Vaccine Administered pneumococcal conjugate vaccine, 13 valent (CVX 133)
PREVNAR 13 (NDC 00005-1971-05)		 Y
Administered Amount (of Vaccine) 0.5 Y
Administered Units (of Measure) mL Y
Administering Provider
J. Martinez Y
Administered-at Location
333 Oceanview Lane, Stamford Connecticut 06901
Y
Lot Number P343V8445 Y
Substance Expiration Date 3/30/2012 Y
Substance Manufacturer Name Pfizer, Inc (MVX PFR) Y
Completion Status CP Y
Route of Administration Intramuscular (NCIT IM) Y
Administration Site Left Thigh (HL7 LT)  
     
Pneumococcal Dose 3 of 4  
Entered BY Sandra Molina
Ordering Provider Carlos Herrera
Entering Organization Shoreline Pediatrics
Vaccine Event information source Historical Immunization (NIP001 01)
Value/Text for Vaccine Type  pneumococcal conjugate vaccine, 13 valent (CVX 133)
Date/Time of Start of Administration 5/21/2012
Vaccine Administered pneumococcal conjugate vaccine, 13 valent (CVX 133)
PREVNAR 13 (NDC 00005-1971-05)
Administered Amount (of Vaccine) 0.5
Administered Units (of Measure) mL
Administering Provider
J. Martinez
Administered-at Location
333 Oceanview Lane, Stamford Connecticut 06901
Lot Number P853V2175
Substance Expiration Date 8/30/2012
Substance Manufacturer Name Pfizer, Inc (MVX PFR)
Completion Status CP
Route of Administration Intramuscular (NCIT IM)
Administration Site RightThigh (HL7 RT)
Pneumococcal Dose 4 of 4  
Entered BY Sandra Molina
Ordering Provider Carlos Herrera
Entering Organization Shoreline Pediatrics
Vaccine Event information source Historical Immunization (NIP001 01)
Value/Text for Vaccine Type  pneumococcal conjugate vaccine, 13 valent (CVX 133)
Date/Time of Start of Administration 11/22/2012
Vaccine Administered pneumococcal conjugate vaccine, 13 valent (CVX 133)
PREVNAR 13 (NDC 00005-1971-05)
Administered Amount (of Vaccine) 0.5
Administered Units (of Measure) mL
Administering Provider
J. Martinez
Administered-at Location
333 Oceanview Lane, Stamford Connecticut 06901
Lot Number P853V58544
Substance Expiration Date 4/18/2013
Substance Manufacturer Name Pfizer, Inc (MVX PFR)
Completion Status CP
Route of Administration Intramuscular (NCIT IM)
Administration Site Left Deltoid (HL7 LD)

Notes to Testers

No Note

1.2.8. Enter Rotavirus Dose1 and 2 of 3 Juan Marcel

Test Step Type: SUT_MANUAL
Patient History for Rotavirus is entered into the EMR for Juan Marcel Gonzales.

Test Story

Description

The EHR vendor loads Rotavirus immunization history data  for Juan Marcel Gonzales.

Comments

No Comments

PreCondition

The EMR has recorded all of the pediatric demographic in the record created for Juan Marcel Gonzales.

PostCondition

The immunization history for Rotavirus known to the local practice is loaded into the record created for Juan Marcel Gonzales.

Test Objectives

Record Past Immunizations: The EHR or other clinical software system allows providers to enter information about immunizations given elsewhere (e.g., by another doctor, at a public health clinic, pharmacy, etc.) with incomplete details.

Evaluation Criteria

Evaluation Criteria: Vendor successfully records all immunization data known to the local practice as provided, with all required attributes indicated by [Y]:

Rotavirus Dose 1 of 3    
Entered BY Sandra Molina Y
Ordering Provider Jane Carter Y
Entering Organization Shoreline Pediatrics Y
Administration Notes (Vaccine Event information source) Historical Immunization (NIP001 01) Y
Date/Time of Start of Administration 1/22/2012 Y
Vaccine Administered rotavirus, live, monovalent vaccine (CVX 119)
ROTARIX (NDC 58160-0854-52)		 Y
Administered Amount (of Vaccine) 0.5 Y
Administered Units (of Measure) mL Y
Administering Provider Jane Carter Y
Administered-at Location 325 Shorline Drive,  Stamford Connecticut 06901 Y
Lot Number 6359RV533 Y
Substance Expiration Date 2/15/2010 Y
Substance Manufacturer Name GlaxoSmithKline Biologicals SA (MVX SKB) Y
Completion Status CP Y
Route of Administration Intramuscular (NCIT C28161, HL70162: IM) Y
Administration Site Left Thigh (HL7 LT) Y
     
Rotavirus Dose 2 of 3    
Entered BY Sandra Molina Y
Ordering Provider Carlos Herrera Y
Entering Organization Shoreline Pediatrics Y
Vaccine Event information source Historical Immunization (NIP001 01) Y
Value/Text for Vaccine Type  rotavirus, live, monovalent vaccine (CVX 119) Y
Date/Time of Start of Administration 3/22/2012 Y
Vaccine Administered rotavirus, live, monovalent vaccine (CVX 119)
ROTARIX (NDC 58160-0854-52)		 Y
Administered Amount (of Vaccine) 0.5 Y
Administered Units (of Measure) mL Y
Administering Provider
J. Martinez Y
Administered-at Location
333 Oceanview Lane, Stamford Connecticut 06901
Y
Lot Number 6359RV932 Y
Substance Expiration Date 5/10/2011 Y
Substance Manufacturer Name GlaxoSmithKline Biologicals SA (MVX SKB) Y
Completion Status CP Y
Route of Administration Intramuscular (NCIT IM) Y
Administration Site Right Thigh (HL7 RT)  

Notes to Testers

No Note

1.2.9. Enter Influenza History Doses Juan Marcel

Test Step Type: SUT_MANUAL
Patient History for Influenza is entered into the EMR for Juan Marcel.

Test Story

Description

The EHR vendor loads Influenza immunization history data  for Juan Marcel Gonzales.

Comments

No Comments

PreCondition

The EMR has recorded all of the pediatric demographic in the record created for Juan Marcel Gonzales.

PostCondition

The immunization history for Influenza known to the local practice is loaded into the record created for Juan Marcel Gonzales.

Test Objectives

Record Past Immunizations: The EHR or other clinical software system allows providers to enter information about immunizations given elsewhere (e.g., by another doctor, at a public health clinic, pharmacy, etc.) with incomplete details.

Evaluation Criteria

Evaluation Criteria: Vendor successfully records all immunization data known to the local practice as provided, with all required attributes indicated by [Y]:

Influenza Dose 1 of 2    
Entered BY Sandra Molina Y
Ordering Provider Carlos Herrera Y
Entering Organization Shoreline Pediatrics Y
Administration Notes (Vaccine Event information source) Historical Immunization (NIP001 01) Y
Date/Time of Start of Administration 9/22/2012 Y
Vaccine Administered Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161)
FLUZONE QUADRIVALENT (NDC 49281-0514-25)		 Y
Administered Amount (of Vaccine) 0.25 Y
Administered Units (of Measure) mL Y
Administering Provider Y
Administered-at Location 333 Oceanview Lane, Stamford Connecticut 06901 Y
Lot Number D8043IN8734 Y
Substance Expiration Date 3/12/2013 Y
Substance Manufacturer Name Sanofi Pasteur Inc (MVX PMC) Y
Completion Status CP Y
Route of Administration Intramuscular (NCIT C28161, HL70162: IM) Y
Administration Site Left Thigh (HL7 LT) Y
     
Influenza Dose 2 of 2    
Entered BY Sandra Molina Y
Ordering Provider Carlos Herrera Y
Entering Organization Shoreline Pediatrics Y
Vaccine Event information source Historical Immunization (NIP001 01) Y
Value/Text for Vaccine Type  Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) Y
Date/Time of Start of Administration 10/20/2012 Y
Vaccine Administered Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161)
FLUZONE QUADRIVALENT (NDC 49281-0514-25)		 Y
Administered Amount (of Vaccine) 0.25 Y
Administered Units (of Measure) mL Y
Administering Provider
J. Martinez Y
Administered-at Location
333 Oceanview Lane, Stamford Connecticut 06901
Y
Lot Number D8043IN8798 Y
Substance Expiration Date 3/12/2013 Y
Substance Manufacturer Name Sanofi Pasteur Inc (MVX PMC) Y
Completion Status CP Y
Route of Administration Intramuscular (NCIT IM) Y
Administration Site Right Thigh (HL7 RT)  
     
Influenza Annual Dose  
Entered BY Sandra Molina
Ordering Provider Carlos Herrera
Entering Organization Shoreline Pediatrics
Vaccine Event information source Historical Immunization (NIP001 01)
Value/Text for Vaccine Type  Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161)
Date/Time of Start of Administration 10/30/2013
Vaccine Administered Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161)
FLUZONE QUADRIVALENT (NDC 49281-0514-25)
Administered Amount (of Vaccine) 0.25
Administered Units (of Measure) mL
Administering Provider
J. Martinez
Administered-at Location
333 Oceanview Lane, Stamford Connecticut 06901
Lot Number D8043IN8734
Substance Expiration Date 5/22/2014
Substance Manufacturer Name Sanofi Pasteur Inc (MVX PMC)
Completion Status CP
Route of Administration Intramuscular (NCIT IM)
Administration Site Left Deltoid (HL7 LD)

Notes to Testers

No Note

1.2.10. Enter HepA Dose1 and 2 of 2 Juan Marcel

Test Step Type: SUT_MANUAL
Patient History for HepA is entered into the EMR for Juan Marcel Gonzales.

Test Story

Description

The EHR vendor loads HepA immunization history data  for Juana Mariana Gonzales.

Comments

No Comments

PreCondition

The EMR has recorded all of the pediatric demographic in the record created for Juana Mariana Gonzales.

PostCondition

The immunization history for HepA known to the local practice is loaded into the record created for Juana Mariana Gonzales.

Test Objectives

Record Past Immunizations: The EHR or other clinical software system allows providers to enter information about immunizations given elsewhere (e.g., by another doctor, at a public health clinic, pharmacy, etc.) with incomplete details.

Evaluation Criteria

Evaluation Criteria: Vendor successfully records all immunization data known to the local practice as provided, with all required attributes indicated by [Y]:

HepA Dose 1 of 2    
Entered BY Sandra Molina Y
Ordering Provider Jane Carter Y
Entering Organization Shoreline Pediatrics Y
Administration Notes (Vaccine Event information source) Historical Immunization (NIP001 01) Y
Date/Time of Start of Administration 11/23/2011 Y
Vaccine Administered hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule (CVX 83)
HAVRIX (NDC 58160-0825-52)		 Y
Administered Amount (of Vaccine) 0.5 Y
Administered Units (of Measure) mL Y
Administering Provider Jane Carter Y
Administered-at Location 325 Shorline Drive,  Stamford Connecticut 06901 Y
Lot Number 6359RT33 Y
Substance Expiration Date 1/4/2012 Y
Substance Manufacturer Name GlaxoSmithKline Biologicals SA (MVX SKB) Y
Completion Status CP Y
Route of Administration Intramuscular (NCIT C28161, HL70162: IM) Y
Administration Site Right Deltoid (HL7 RD) Y
     
HepA Dose 2 of 2    
Entered BY Sandra Molina Y
Ordering Provider Carlos Herrera Y
Entering Organization Shoreline Pediatrics Y
Vaccine Event information source Historical Immunization (NIP001 01) Y
Value/Text for Vaccine Type  hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule (CVX 83) Y
Date/Time of Start of Administration 5/23/2012 Y
Vaccine Administered hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule (CVX 83)
HAVRIX (NDC 58160-0825-52)		 Y
Administered Amount (of Vaccine) 0.5 Y
Administered Units (of Measure) mL Y
Administering Provider
J. Martinez Y
Administered-at Location
333 Oceanview Lane, Stamford Connecticut 06901
Y
Lot Number 6359RT48 Y
Substance Expiration Date 9/11/2012 Y
Substance Manufacturer Name GlaxoSmithKline Biologicals SA (MVX SKB) Y
Completion Status CP Y
Route of Administration Intramuscular (NCIT C28161, HL70162: IM) Y
Administration Site Left Deltoid (HL7 LD)  

Notes to Testers

No Note

1.2.11. Enter MMRV Dose1 of 3 Juan Marcel

Test Step Type: SUT_MANUAL
Patient History for MMRV is entered into the EMR for Juan Marcel Gonzales.

Test Story

Description

The EHR vendor loads MMRV immunization history data  for Juan Marcel Gonzales.

Comments

None

PreCondition

The EMR has recorded all of the pediatric demographic in the record created for Juan Marcel Gonzales.

PostCondition

The immunization history for MMRV known to the local practice is loaded into the record created for Juan Marcel Gonzales.

Test Objectives

Record Past Immunizations: The EHR or other clinical software system allows providers to enter information about immunizations given elsewhere (e.g., by another doctor, at a public health clinic, pharmacy, etc.) with incomplete details.

Evaluation Criteria

Evaluation Criteria: Vendor successfully records all immunization data known to the local practice as provided, with all required attributes indicated by [Y]:

MMRV Dose 1 of 3    
Entered BY Sandra Molina Y
Ordering Provider Jane Carter Y
Entering Organization Shoreline Pediatrics Y
Administration Notes (Vaccine Event information source) Historical Immunization (NIP001 01) Y
Date/Time of Start of Administration 11/22/2012 Y
Vaccine Administered measles, mumps, rubella, and varicella virus vaccine (CVX 94)
ProQuad (NDC 00006-4999-00)		 Y
Administered Amount (of Vaccine) 0.5 Y
Administered Units (of Measure) mL Y
Administering Provider Jane Carter Y
Administered-at Location 325 Shorline Drive,  Stamford Connecticut 06901 Y
Lot Number 7W27V7632 Y
Substance Expiration Date 12/15/2016 Y
Substance Manufacturer Name Merck Sharp & Dohme Corp (MVX MSD) Y
Completion Status CP Y
Route of Administration Subcutaneous (NCIT C38299, HL70162: SC) Y
Administration Site Left Thigh (HL7 LT) Y

Notes to Testers

No Note

1.3. Mariela Gonzales Morales Initial Data Load

Demonstrates the ability to record pediatric demographic data, historical vaccinations, and clinical conditions for infant twin Mariela Gonzales Morales. There are no transactions associated with this test case.

Test Story

Description
No Description

Comments
No Comments

PreCondition
No PreCondition

PostCondition
No PostCondition

Test Objectives
No Test Objectives

Evaluation Criteria
No evaluation criteria

Notes to Testers
No Note

1.3.1. Enter Initial Demographic Data for Mariela Gonzales Morales

Test Step Type: SUT_MANUAL
Mariela Gonzales Morales, infant twin, is entered as a new patient in the EMR, including all pediatric demographic information.

Test Story

Description

The EHR vendor loads demographic data for Mariela Gonzales Morales.

Comments

Set-up step evaluating EMR functions for capturing and storing patient pediatric demographic data. There is no transaction associated with this test step.

PreCondition

No PreCondition

PostCondition

The EMR has recorded all of the pediatric demographic  in the record created for Mariela Gonzales Morales.

Test Objectives

Register New Patients: The system must allow a user to enter distinguishing information about patients so that providers can uniquely identify patients who have similar sounding names or other similar identifying information.  For example, twins living in the same household will have similar dates of birth, addresses, and may have similar names. EHRs or other clinical software must be able to store information to successfully match with patients in immunization registries, if the information is available. The information includes the mother’s maiden name, whether the patient was part of a multiple birth, and the order of the multiple birth. This information allows the provider to correctly identify the patient and also helps assure a match when the EHR send the patient’s information to external systems such as an immunization registry.

Evaluation Criteria

Evaluation Criteria: Vendor successfully records all demographic data provided, and in particular (Mother's maiden name, multiple birth, birth order), with all required attributes indicated by [Y]:

Patient ID (previously listed as “Medicaid Number”)

Vendor supplied

Y

Patient ID: Assigning Authority ID (i.e., owning source)/Facility Name

Shoreline Pediatrics

Y

Patient ID: Type (e.g., medical record number, IIS ID)

Vendor supplied

Y

Patient Name: First 

Mariela

Y

Patient Name: Middle

Gonzales

Y

Patient Name: Last

Morales

Y

Patient Date of Birth

5/30/2015

Y

Birth Time

11am

N

Patient Gender (Administrative Sex)

F

Y

Patient Multiple Birth Indicator

Yes

Y

Patient Birth Order

1

C

Responsible Person Name: First

Joanna

Y

Responsible Person Name: Middle

Elena

Y

Responsible Person Name: Last

Morales

Y

Responsible Person Name: Relationship to Patient

Mother

Y

Mother’s Name: First

Joanna

Y

Mother’s Name: Middle

Elena

Y

Mother’s Name: Last

Morales

Y

Mother’s Name: Maiden Last

Gonzales

Y

Patient Address: Street

3321 Standish Way

Y

Patient Address: City

Stamford

Y

Patient Address: State

CT

Y

Patient Address: Country

USA

Y

Patient Address: Zipcode

06903

Y

Patient Address: County of Residence

Fairfield

N

Race

Other

Y

Ethnicity

Hispanic or Latino

Y

Birthing Facility Name (Birth Delivery Location Address BDL)

Stamford Regional Hospital
15 Atlantic Avenue, Stamford Connecticut 06903

[Y – birthing

 facility name,

not address]

Patient Birth State

CT

Y

Patient Primary Language

English

Y

Patient Telephone Number

(203) 555-1214

Y

Patient Telephone Number Type (e.g., home, cell)

home

Y

Patient E-mail Address

none

N

Publicity Code

 

N

Protection Indicator

  

N

Protection Indicator Effective Date

  

N

Immunization Registry Status

  

N

Preferred Contact Method

none

  

Notes to Testers

No Note

1.3.2. Enter Initial Clinical Information for Mariela

Test Step Type: SUT_MANUAL
The EHR captures structured data indicating that Mariela has a fever in the current visit.

Test Story

Description

The triage nurse enters basic information on  Mariela Gonzales Morales – she has a fever (Temperature of 100.8o F).

Comments

No Comments

PreCondition

The EMR has recorded all of the pediatric demographic  in the record created for Mariela Gonzales Morales.

PostCondition

The clinical record for Mariela Gonzales Morales indicates that she currently has a fever (temperature 100.8oF)..

Test Objectives

Supporting data for documenting contraindications (it could also trigger an alert as a locally configured alert rule): Modify Antigen Recommendations Based on Active Diagnoses: The system notifies the provider of any conflicts between recommended vaccines in the updated forecast and the patient’s current or historical diagnoses.

Evaluation Criteria

Evaluation Criteria: Vendor successfully records all clinical data provided with all required attributes indicated by [Y]:

Vital Signs Fever of 100.1 (@code LOINC 8310-5 @value 100.1)
Vital Signs Observation Date Date of current visit
Problems (If vendor uses problems for alert computations, then this should be included.) Problem list: ( Low grade pyrexia (finding) 304213008) 
Problem Observation Date Date of current visit

Notes to Testers

No Note

1.3.3. Enter HepB Dose1 of 3 Mariella

Test Step Type: SUT_MANUAL
Patient History for HepB is entered into the EMR for Mariella Gonzales Morales.

Test Story

Description

The EHR vendor loads HepB immunization history data  for Mariela Gonzales Morales.

Comments

No Comments

PreCondition

The EMR has recorded all of the pediatric demographic in the record created for Mariela Gonzales Morales.

PostCondition

The immunization history for HepB known to the local practice is loaded into the record created for Mariela Gonzales Morales.

Test Objectives

Record Past Immunizations: The EHR or other clinical software system allows providers to enter information about immunizations given elsewhere (e.g., by another doctor, at a public health clinic, pharmacy, etc.) with incomplete details.

Evaluation Criteria

Evaluation Criteria: Vendor successfully records all immunization data known to the local practice as provided, with all required attributes indicated by [Y]:

HepB Dose 1 of 3    
Entered BY Sandra Molina Y
Ordering Provider Justin Parker Y
Entering Organization Shoreline Pediatrics Y
Administration Notes (Vaccine Event information source) Historical Immunization (NIP001 01) Y
Date/Time of Start of Administration 5/30/2015 Y
Vaccine Administered hepatitis B vaccine, pediatric or pediatric/adolescent dosage  (CVX 08) Y
Administered Amount (of Vaccine) 0.5 Y
Administered Units (of Measure) mL Y
Administering Provider Jane Carter Y
Administered-at Location 15 Atlantic Avenue, Stamford, CT, 06903 Y
Lot Number 6332FK34 Y
Substance Expiration Date 12/14/2015 Y
Substance Manufacturer Name GlaxoSmithKline Biologicals SA (MVX SKB) Y
Completion Status CP Y
Route of Administration Intramuscular (NCIT C28161, HL70162: IM) Y
Administration Site Left Thigh (HL7 LT) Y

Notes to Testers

No Note

1.4. Juana Maria Gonzales Morales Initial Data Load

Demonstrates the ability to record pediatric demographic data, historical vaccinations, and clinical conditions for infant twin Juana Maria Gonzales Morales. There are no transactions associated with this test case.

Test Story

Description
No Description

Comments
No Comments

PreCondition
No PreCondition

PostCondition
No PostCondition

Test Objectives
No Test Objectives

Evaluation Criteria
No evaluation criteria

Notes to Testers
No Note

1.4.1. Enter Initial Demographic Data for Juana Maria Gonzales Morales

Test Step Type: SUT_MANUAL
Juana Maria Gonzales Morales, infant twin, is entered as a new patient in the EMR, including all pediatric demographic information.

Test Story

Description

The EHR vendor loads demographic data for Juana Maria Gonzales Morales.

Comments

Set-up step evaluating EMR functions for capturing and storing patient pediatric demographic data. There is no transaction associated with this test step.

PreCondition

No PreCondition

PostCondition

The EMR has recorded all of the pediatric demographic  in the record created for Juana Maria Gonzales Morales.

Test Objectives

Register New Patients: The system must allow a user to enter distinguishing information about patients so that providers can uniquely identify patients who have similar sounding names or other similar identifying information.  For example, twins living in the same household will have similar dates of birth, addresses, and may have similar names. EHRs or other clinical software must be able to store information to successfully match with patients in immunization registries, if the information is available. The information includes the mother’s maiden name, whether the patient was part of a multiple birth, and the order of the multiple birth. This information allows the provider to correctly identify the patient and also helps assure a match when the EHR send the patient’s information to external systems such as an immunization registry.

Evaluation Criteria

Evaluation Criteria: Vendor successfully records all demographic data provided, and in particular (Mother's maiden name, multiple birth, birth order), with all required attributes indicated by [Y]:

Patient ID (previously listed as “Medicaid Number”)

Vendor supplied

Y

Patient ID: Assigning Authority ID (i.e., owning source)/Facility Name

Shoreline Pediatrics

Y

Patient ID: Type (e.g., medical record number, IIS ID)

Vendor supplied

Y

Patient Name: First 

Juana

Y

Patient Name: Middle

Maria Gonzales

Y

Patient Name: Last

Morales

Y

Patient Date of Birth

5/30/2015

Y

Birth Time

11:15am

N

Patient Gender (Administrative Sex)

F

Y

Patient Multiple Birth Indicator

Yes

Y

Patient Birth Order

2

C

Responsible Person Name: First

Joanna

Y

Responsible Person Name: Middle

Elena

Y

Responsible Person Name: Last

Morales

Y

Responsible Person Name: Relationship to Patient

Mother

Y

Mother’s Name: First

Joanna

Y

Mother’s Name: Middle

Elena

Y

Mother’s Name: Last

Morales

Y

Mother’s Name: Maiden Last

Gonzales

Y

Patient Address: Street

3321 Standish Way

Y

Patient Address: City

Stamford

Y

Patient Address: State

CT

Y

Patient Address: Country

USA

Y

Patient Address: Zipcode

06903

Y

Patient Address: County of Residence

Fairfield

N

Race

Other

Y

Ethnicity

Hispanic or Latino

Y

Birthing Facility Name (Birth Delivery Location Address BDL)

Stamford Regional Hospital
15 Atlantic Avenue, Stamford Connecticut 06903

[Y – birthing

 facility name,

not address]

Patient Birth State

CT

Y

Patient Primary Language

English

Y

Patient Telephone Number

(203) 555-1214

Y

Patient Telephone Number Type (e.g., home, cell)

home

Y

Patient E-mail Address

none

N

Publicity Code

 

N

Protection Indicator

  

N

Protection Indicator Effective Date

  

N

Immunization Registry Status

  

N

Preferred Contact Method

none

  
  • ]

Notes to Testers

No Note

1.4.2. Enter HepB Dose1 of 3 Juana Maria

Test Step Type: SUT_MANUAL
Patient History for HepB is entered into the EMR for Juana Maria Gonzales Morales.

Test Story

Description

The EHR vendor loads HepB immunization history data  for Juana Maria Gonzales Morales.

Comments

No Comments

PreCondition

The EMR has recorded all of the pediatric demographic in the record created for Juana Maria Gonzales Morales.

PostCondition

The immunization history for HepB known to the local practice is loaded into the record created for Juana Maria Gonzales Morales.

Test Objectives

Record Past Immunizations: The EHR or other clinical software system allows providers to enter information about immunizations given elsewhere (e.g., by another doctor, at a public health clinic, pharmacy, etc.) with incomplete details.

Evaluation Criteria

Evaluation Criteria: Vendor successfully records all immunization data known to the local practice as provided, with all required attributes indicated by [Y]:

HepB Dose 1 of 3    
Entered BY Sandra Molina Y
Ordering Provider Justin Parker Y
Entering Organization Shoreline Pediatrics Y
Administration Notes (Vaccine Event information source) Historical Immunization (NIP001 01) Y
Date/Time of Start of Administration 5/30/2015 Y
Vaccine Administered hepatitis B vaccine, pediatric or pediatric/adolescent dosage  (CVX 08) Y
Administered Amount (of Vaccine) 0.5 Y
Administered Units (of Measure) mL Y
Administering Provider Jane Carter Y
Administered-at Location 15 Atlantic Avenue, Stamford, CT, 06903 Y
Lot Number 6332FK34 Y
Substance Expiration Date 12/14/2015 Y
Substance Manufacturer Name GlaxoSmithKline Biologicals SA (MVX SKB) Y
Completion Status CP Y
Route of Administration Intramuscular (NCIT C28161, HL70162: IM) Y
Administration Site Left Thigh (HL7 LT) Y

Notes to Testers

No Note

2. Display Immunization History and Forecast

The provider will view the immunization history and forecast in the EMR showing all data entered and the resulting forecast for the child.

2.1. Juana Mariana Gonzales Display Immunization History and Forecast

Using the data entered in the Intial Data Load,, the EMR displays an Evaluated History and Forecast to the user to inform the visit for Juana Mariana Gonzales.

Test Story

Description
No Description

Comments
No Comments

PreCondition
No PreCondition

PostCondition
No PostCondition

Test Objectives
No Test Objectives

Evaluation Criteria
No evaluation criteria

Notes to Testers
No Note

2.1.1. Display the Evaluated Immunization History

Test Step Type: SUT_MANUAL
The Provider uses the EMR to view the immunization history sin Juana Mariana Gonzales' record in the local system.

Test Story

Description

The provider views the complete Evaluated History for Juana Mariana Gonzales.

Comments

No Comments

PreCondition

All Demographic and Immunizations have been entered from the Initial Data Load.

PostCondition

The complete Evaluated History for Juana Mariana Gonzales is displayed to the user.

Test Objectives

Review Patient Immunization History: To assist with the ordering process, the EHR or other clinical software system allows a user to specify standard views of patient immunization information for each vaccine dose administration, including patient-specific data (e.g., age on dates of administration, etc.).

Evaluation Criteria
1. The user views vaccinations as follows:

b. Vaccinations displayed:

hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08)  administered 1/15/2010
hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08)  administered 10/30/2010
diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) administered 1/22/2010
diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) administered 3/23/2010,
Including adverse reaction 31044-1 Reaction, VXC12^fever of >40.5C (105F) within 48 hours of dose
diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) administered 5/22/2010
diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) administered 2/21/2011
Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) administered 1/22/2010
Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) administered 3/23/2010
Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) administered 5/22/2010
Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) administered 2/21/2011
poliovirus vaccine, inactivated (CVX 10) administered 1/22/2010
poliovirus vaccine, inactivated (CVX 10) administered 3/23/2010
pneumococcal conjugate vaccine, 13 valent (CVX 133) administered 1/22/2010
pneumococcal conjugate vaccine, 13 valent (CVX 133) administered 3/23/2010
pneumococcal conjugate vaccine, 13 valent (CVX 133) administered 5/22/2010
pneumococcal conjugate vaccine, 13 valent (CVX 133) administered 2/21/2011
rotavirus, live, monovalent vaccine (CVX 119) administered 3/23/2010
Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) administered 9/25/2010
Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) administered 10/27/2010
Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) administered 10/2/2011
Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) administered 11/4/2012
hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule (CVX 83) administered 11/23/2011
hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule (CVX 83) administered 5/23/2012
measles, mumps, rubella, and varicella virus vaccine (CVX 94) administered 10/23/2010 --Identified as an invalid dose
measles, mumps, rubella, and varicella virus vaccine (CVX 94) administered 11/22/2012
 

Notes to Testers

No Note

2.1.2. View the vaccination forecast for Juana Mariana Gonzales

Test Step Type: SUT_MANUAL
Using the vaccine history information, the EMR displays the current Immunization Forecast to the user for Juana Mariana Gonzales.

Test Story

Description

Once the vaccine history is entered in the EMR, the provider views the vaccine forecast. 

Comments

No Comments

PreCondition

Vaccine History is is available in the EMR record for Juana Mariana Gonzales.

PostCondition

A vaccine forecast based upon the complete vaccine history in the EMR is available to the user. 

Test Objectives

View Reconciled Immunization Forecast: The EHR or other clinical software system has the ability to re-evaluate and update the immunization forecast using a patient’s newly updated immunization history, where the updated forecast results from the reconciliation of immunization data contained in the public health immunization registry with immunization data contained in the EHR. Processing the new forecast can be internal to the EHR or it can use an external forecasting service.

Evaluation Criteria

Tester verifies that the vendor can display the immunization forecast based upon the reconciled vaccination history:

1. Verify that the EMR does not include in reconciled vaccine forecast:
IPV due on 5/22/2010
2. Verify that the EMR includes in reconciled vaccine forecast:
IPV due on 11/22/2013
MMR due on 5/22/2011
Varicella due on 5/22/2011
influenza, unspecified formulation due on 10/21/2015
 

Notes to Testers

No Note

2.2. Juan Marcel Gonzales Display Immunization History and Forecast

Using the data entered in the Intial Data Load, the EMR displays an Evaluated History and Forecast to the user to inform the visit for Juan Marcel Gonzales.

Test Story

Description
No Description

Comments
No Comments

PreCondition
No PreCondition

PostCondition
No PostCondition

Test Objectives
No Test Objectives

Evaluation Criteria
No evaluation criteria

Notes to Testers
No Note

2.2.1. Display the Evaluated Immunization History for Juan Marcel Gonzales

Test Step Type: SUT_MANUAL
The Provider uses the EMR to view the immunization history in Juan Marcel Gonzales ' record in the local system.

Test Story

Description

The provider views the complete Evaluated History for Juan Marcel Gonzales.

Comments

None

PreCondition

All Demographic and Immunizations have been entered from the Initial Data Load.

PostCondition

The complete Evaluated History for Juan Marcel Gonzales is displayed to the user.

Test Objectives

Review Patient Immunization History: To assist with the ordering process, the EHR or other clinical software system allows a user to specify standard views of patient immunization information for each vaccine dose administration, including patient-specific data (e.g., age on dates of administration, etc.).

Evaluation Criteria
1. The user views vaccinations as follows:

b. Vaccinations displayed:

hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08)  administered 11/23/2011
hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08)  administered 12/23/2013
diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) administered 1/22/2012
diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) administered 3/22/2012
diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) administered 5/21/2012
diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106) administered 2/20/2013
Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) administered 1/22/2012
Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) administered 3/22/2012
Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) administered 5/21/2012
Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49) administered 11/22/2012
poliovirus vaccine, inactivated (CVX 10) administered 1/22/2012
poliovirus vaccine, inactivated (CVX 10) administered 3/22/2012
poliovirus vaccine, inactivated (CVX 10) administered 5/21/2012
pneumococcal conjugate vaccine, 13 valent (CVX 133) administered 1/22/2012
pneumococcal conjugate vaccine, 13 valent (CVX 133) administered 3/22/2012
pneumococcal conjugate vaccine, 13 valent (CVX 133) administered 5/21/2012
pneumococcal conjugate vaccine, 13 valent (CVX 133) administered 11/22/2012
rotavirus, live, monovalent vaccine (CVX 119) administered 1/22/2012
rotavirus, live, monovalent vaccine (CVX 119) administered 3/22/2012
Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) administered 9/22/2012
Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) administered 10/20/2012
Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161) administered 10/30/2013
hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule (CVX 83) administered 5/21/2013
hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule (CVX 83) administered 12/1/2013
measles, mumps, rubella, and varicella virus vaccine (CVX 94) administered 11/22/2012
 
 

Notes to Testers

No Note

2.2.2. View the vaccination forecast for Juan Marcel Gonzales

Test Step Type: SUT_MANUAL
Using the vaccine history information, the EMR displays the current Immunization Forecast to the user for Juan Marcel Gonzales.

Test Story

Description

Once the vaccine history is entered in the EMR, the provider views the vaccine forecast.

Comments

None

PreCondition

Vaccine History is is available in the EMR record for Juana Mariana Gonzales.

PostCondition

A vaccine forecast based upon the complete vaccine history in the EMR is available to the user.

Test Objectives

View Reconciled Immunization Forecast: The EHR or other clinical software system has the ability to re-evaluate and update the immunization forecast using a patient’s newly updated immunization history, where the updated forecast results from the reconciliation of immunization data contained in the public health immunization registry with immunization data contained in the EHR. Processing the new forecast can be internal to the EHR or it can use an external forecasting service.

Evaluation Criteria

1. Tester verifies that the vendor can display the immunization forecast based upon the reconciled vaccination history:
2. Verify that the EMR includes in the vaccine forecast:

Hep B Peds NOS due on 5/21/2012
DTaP due on 11/22/2015
IPV due on 11/22/2015
MMR due on 11/22/2015
Varicella due on 11/22/2015
influenza, unspecified formulation due on Oct 22, 2015 or later

Notes to Testers

No Note

2.3. Mariela Gonzales Morales Display Immunization History and Forecast

Using the data entered in the Intial Data Load, the EMR displays an Evaluated History and Forecast to the user to inform the visit for Mariela Gonzales Morales.

Test Story

Description
No Description

Comments
No Comments

PreCondition
No PreCondition

PostCondition
No PostCondition

Test Objectives
No Test Objectives

Evaluation Criteria
No evaluation criteria

Notes to Testers
No Note

2.3.1. Display the Evaluated Immunization History for Mariela Gonzales Morales

Test Step Type: SUT_MANUAL
The Provider uses the EMR to view the immunization history in Mariela Gonzales Morales ' record in the local system.

Test Story

Description

The provider views the complete Evaluated History for Mariela Gonzales Morales.

Comments

None

PreCondition

All Demographic and Immunizations have been entered from the Initial Data Load.

PostCondition

The complete Evaluated History for Mariela Gonzales Morales is displayed to the user.

Test Objectives

Review Patient Immunization History: To assist with the ordering process, the EHR or other clinical software system allows a user to specify standard views of patient immunization information for each vaccine dose administration, including patient-specific data (e.g., age on dates of administration, etc.).

Evaluation Criteria
1. The user views vaccinations as follows:

b. Vaccinations displayed:

hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08)  administered 5/30/2015

Notes to Testers

No Note

2.3.2. View the vaccination forecast for Mariela Gonzales Morales

Test Step Type: SUT_MANUAL
The EMR displays the current Immunization Forecast to the user for Mariela Gonzales Morales either as returned by the IIS in prior step, or as generated thru any local means.

Test Story

Description

The physician accesses the record for Mariela Gonzales Morales and:

• Views the vaccine forecast (either as provided by the Immunization Registry or as determined through EMR defined methods)

Comments

No Comments

PreCondition

EMR Vaccine History is imported from the Immunization History returned from the Immunization Registry (previous step 'View and import response to request for vaccination history for Mariela Gonzales Morales)

PostCondition

A vaccine forecast based upon the imported vaccine history is available to the user. 

Test Objectives

View Reconciled Immunization Forecast: The EHR or other clinical software system has the ability to re-evaluate and update the immunization forecast using a patient’s newly updated immunization history, where the updated forecast results from the reconciliation of immunization data contained in the public health immunization registry with immunization data contained in the EHR. Processing the new forecast can be internal to the EHR or it can use an external forecasting service.

Evaluation Criteria

1. Tester verifies that the vendor can display the immunization forecast based upon the reconciled vaccination history:
2. Verify that the EMR includes in the vaccine forecast:

Hep B Peds NOS due on 6/29/2015
DTaP due on 7/29/2015
Hib due on 7/29/2015
IPV due on 7/29/2015
Pneumococcal conjugate due on 7/29/2015
Rotavirus due on 7/29/2015
  HepA due on 5/29/2016
  MMR due on 5/29/2016
Varicella due on 5/29/2016
influenza, unspecified formulation due on Nov 26, 2015 or later

Notes to Testers

No Note

2.4. Juana Maria Gonzales Morales Display Immunization History and Forecast

Using the data entered in the Intial Data Load, the EMR displays an Evaluated History and Forecast to the user to inform the visit for Juana Maria Gonzales Morales.

Test Story

Description
No Description

Comments
No Comments

PreCondition
No PreCondition

PostCondition
No PostCondition

Test Objectives
No Test Objectives

Evaluation Criteria
No evaluation criteria

Notes to Testers
No Note

2.4.1. Display the Evaluated Immunization History for Juana Maria Gonzales Morales

Test Step Type: SUT_MANUAL
The Provider uses the EMR to view the immunization history in Juana Maria Gonzales Morales ' record in the local system.

Test Story

Description

The provider views the complete Evaluated History for Juana Maria Gonzales Morales.

Comments

None

PreCondition

All Demographic and Immunizations have been entered from the Initial Data Load.

PostCondition

The complete Evaluated History for Juana Maria Gonzales Morales is displayed to the user.

Test Objectives

Review Patient Immunization History: To assist with the ordering process, the EHR or other clinical software system allows a user to specify standard views of patient immunization information for each vaccine dose administration, including patient-specific data (e.g., age on dates of administration, etc.).

Evaluation Criteria
1. The user views vaccinations as follows:

b. Vaccinations displayed:

hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08)  administered 3/30/2015

Notes to Testers

No Note

2.4.2. View the vaccination forecast for Juana Maria Gonzales Morales

Test Step Type: SUT_MANUAL
The EMR displays the current Immunization Forecast to the user for Juana Maria Gonzales Morales either as returned by the IIS in prior step, or as generated thru any local means.

Test Story

Description

The physician accesses the record for Juana Maria Gonzales Morales and:

• Views the vaccine forecast (either as provided by the Immunization Registry or as determined through EMR defined methods)

Comments

No Comments

PreCondition

EMR Vaccine History is imported from the Immunization History returned from the Immunization Registry (previous step 'View and import response to request for vaccination history for Juana Maria Gonzales Morales)

PostCondition

A vaccine forecast based upon the imported vaccine history is available to the user.


Test Objectives

View Reconciled Immunization Forecast: The EHR or other clinical software system has the ability to re-evaluate and update the immunization forecast using a patient’s newly updated immunization history, where the updated forecast results from the reconciliation of immunization data contained in the public health immunization registry with immunization data contained in the EHR. Processing the new forecast can be internal to the EHR or it can use an external forecasting service.

Evaluation Criteria

1. Tester verifies that the vendor can display the immunization forecast based upon the reconciled vaccination history:
2. Verify that the EMR includes in the vaccine forecast:

Hep B Peds NOS due on 6/29/2015
DTaP due on 7/29/2015
Hib due on 7/29/2015
IPV due on 7/29/2015
Pneumococcal conjugate due on 7/29/2015
Rotavirus due on 7/29/2015
  HepA due on 5/29/2016
  MMR due on 5/29/2016
Varicella due on 5/29/2016
influenza, unspecified formulation due on Nov 26, 2015 or later

Notes to Testers

No Note

3. Order and Immunize patient

This test will consist of ordering vaccines for the test patients, reviewing any alerts caused by specific scenarios, and documenting vaccinations administered to the patients. NOTE: There are no orders or immunizations in this test plan for Juana Maria Gonzales.

3.1. Juana Mariana Gonzales, Enter Orders and Immunizations

Orders and Immunization events, non-administrations, and alerts presented for current visit.

Test Story

Description
No Description

Comments
No Comments

PreCondition
No PreCondition

PostCondition
No PostCondition

Test Objectives
No Test Objectives

Evaluation Criteria
No evaluation criteria

Notes to Testers
No Note

3.1.1. Order IPV and view prior reaction

Test Step Type: SUT_MANUAL
The provider selects to order IPV and views information about the prior febrile seizure post-IPV vaccine.

Test Story

Description

The physician accesses the record for Juana Mariana Gonzales and:

• Selects order for IPV and views information about the prior febrile seizure post-IPV vaccine

Comments

No Comments

PreCondition

Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR.

PostCondition

IPV order entered in patient record. User notified of history of adverse reaction to IPV (febrile seizures).

Test Objectives

Notify of Previous Adverse Event: EHRs and other clinical software systems alert providers to previous adverse events for a specific patient, in order to inform clinical decision-making when providers view an existing immunization record.

Evaluation Criteria

EMR Records the following order information and Alert:

Entered BY Sandra Molina
Ordering Provider Frank Smith
Entering Organization Shoreline Pediatrics
Vaccine Event information source New immunization record (NIP001 00)
Value/Text for Vaccine Type  IPV (CVX 10)
Date/Time Vaccine Refusal was recorded Current Date
Alert  Alerts user to information about the prior febrile seizure post-IPV vaccine

Notes to Testers

No Note

3.1.2. IPV Parental Refusal

Test Step Type: SUT_MANUAL
Documents mother?s refusal for IPV vaccine indicating the parent decision, the reason and makes it permanent.

Test Story

Description

The mother is concerned about administering the IPV due to the prior adverse reaction, and refuses to have the child immunized for IPV. The provider documents mother’s refusal for IPV vaccine indicating the parent decision, the reason and makes it permanent.

Comments

No Comments

PreCondition

Prior Immunization History loaded and reconciled from the Immunization Registry. Order is attempted for IPV. Provider has been alerted to prior adverse reaction to IPV of febrile seizures.

PostCondition

Vaccine non-administration due to parental refusal is documented in the patient record. Deferral is permanent.

Test Objectives

Record Vaccine Administration Deferral: The EHR or other clinical software system allows a user to enter a reason or reasons why a specific immunization was not given to a patient (e.g., due to contraindication, refusal, etc.).  The system also stores that information in a structured way so it can be reported and analyzed as needed.

Evaluation Criteria

EMR documents the non-administration of the IPV due to the parental refulsal:

Substance/Treatment Refusal Reason Parental decision (NIP002 00)
Completion Status RE
Date/Time Vaccine Deferral was recorded Current Date
Deferral Reason Parental decision (NIP002 00)
Deferral Status Permanent

Notes to Testers

No Note

3.1.3. Order Influenza vaccine and view allergy alert

Test Step Type: SUT_MANUAL
The provider orders inactivated influenza vaccine and is notified that the patient as allergy to egg albumin.

Test Story

Description

The provider orders inactivated influenza vaccine and is notified that the patient as allergy to egg albumin

Comments

No Comments

PreCondition

Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR.

PostCondition

Intranasal form of the Influenza vaccine is ordered for the patient.


Test Objectives

Modify Antigen Recommendations Based on Allergy History: The system notifies the provider of any conflicts between recommended vaccines in the updated forecast and the patient’s active allergies.

Evaluation Criteria

EMR Records the following order information and Alert:

Entered BY Sandra Molina
Ordering Provider Frank Smith
Entering Organization Shoreline Pediatrics
Vaccine Event information source New immunization record (NIP001 00)
Order Value/Text for Vaccine Type  Influenza, injectable,quadrivalent, preservative free, pediatric (CVX161)
Date/Time Vaccine  was recorded Current Date
Alert Alerts user to information that patient has Egg Allergy

 

Provider changes the order to modifies the Vaccine type:

Vaccine Type:  Influenza virus vaccine, live, attenuated, for intranasal use (CVX 111)

Notes to Testers

No Note

3.1.4. Order MMRV Vaccine

Test Step Type: SUT_MANUAL
The provider orders an MMRV vaccine as a catch-up dose.

Test Story

Description

As indicated by the vaccine forecast, the first MMRV administered was invalid as it was administered too soon. The provider orders MMRV as a catch-up dose.

Comments

No Comments

PreCondition

Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR.

PostCondition

MMRV vaccine is ordered for the patient.

Test Objectives

Enter Vaccination Order: The EHR or other clinical software system allows providers to order immunizations for a patient using filters for type of vaccine, including combination vaccines.

Evaluation Criteria

EMR Records the following order information and Alert:

Entered BY Sandra Molina
Ordering Provider Frank Smith
Entering Organization Shoreline Pediatrics
Vaccine Event information source New immunization record (NIP001 00)
Order Value/Text for Vaccine Type  measles, mumps, rubella, and varicella virus vaccine (CVX 94 )
Date/Time Vaccine  was recorded Current Date

Notes to Testers

No Note

3.1.5. Records Influenza Vaccine administration route with data validation checking

Test Step Type: SUT_MANUAL
The provider records the vaccine administration in the EMR and is prevented from incorrectly documenting vaccine route.

Test Story

Description

The nurse documents administration route for the nasal live, attenuated influenza vaccine
• Is prevented from documenting “IM” for live, attenuated influenza vaccine
 

Comments

This step covers data quality checking as an informative aspect of vaccine administration

PreCondition

Order is placed for nasal live, attenuated influenza vaccine.

PostCondition

The nasal live, attenuated influenza vaccination route has failed to be recorded as intramuscular in the EMR.

Test Objectives

Record Vaccine Administration: The EHR or other clinical software system records information about each vaccine administered.  The EHR records this information as structured data elements, including, at a minimum: date administered, administering clinician, site of administration (e.g., left arm), immunization type, product, lot number, manufacturer, Vaccine Information Statement date, and quantity of vaccine/dose size.

Sample of data quality checking for vaccine route.

Evaluation Criteria

The EMR prevents the user for entering 'Intramuscular' as a route for the the nasal live, attenuated influenza vaccine.

Notes to Testers

No Note

3.1.6. Record Influenza Vaccine administration

Test Step Type: SUT_MANUAL
The provider documents in the EMR all attributes associated with the new vaccine administration.

Test Story

Description

 

 

The nurse administers the the nasal live, attenuated influenza vaccine
• Documents all required information for each vaccine

 

 

Comments

No Comments

PreCondition

Order is placed for nasal live, attenuated influenza vaccine.

PostCondition

The nasal live, attenuated influenza vaccinations is recorded in the EMR.

Test Objectives

Record Vaccine Administration: The EHR or other clinical software system records information about each vaccine administered.  The EHR records this information as structured data elements, including, at a minimum: date administered, administering clinician, site of administration (e.g., left arm), immunization type, product, lot number, manufacturer, Vaccine Information Statement date, and quantity of vaccine/dose size.

Evaluation Criteria

EMR Records the following vaccine administration information:

Entered BY Sandra Molina
Ordering Provider Frank Smith
Entering Organization Shoreline Pediatrics
Vaccine Event information source (Administration Notes) New immunization record (NIP001 00)
Value/Text for Vaccine Type  influenza virus vaccine, live, attenuated, for intranasal use (CVX 111), FluMist Quadrivalent (NDC 66019-0301-10)
Date/Time of Start of Administration Current Date
Vaccine Administered influenza virus vaccine, live, attenuated, for intranasal use (CVX 111), FluMist Quadrivalent (NDC 66019-0301-10)
Administered Amount (of Vaccine) 0.2
Administered Units (of Measure) mL
Administering Provider Sandra Molina
Administered-at Location 400 Shoreline Drive, Stamford Connecticut 06901
Lot Number 8L4B3521
Substance Expiration Date 8/15/2015
Substance Manufacturer Name MedImmune,LLC (MVX MED)
Completion Status CP
Route of Administration Nasal (NCIT C38284), Nasal (HL70162 NS)
Administration Site  
VFC Eligibility No

                  

 

Notes to Testers

No Note

3.1.7. Records MMRV Vaccine administration route with data validation checking

Test Step Type: SUT_MANUAL
The provider records the vaccine administration route in the EMR and is prevented from incorrectly documenting vaccine route

Test Story

Description

The nurse documents administration route for the MMRV vaccine
• Is prevented from documenting “oral” for MMRV vaccine
 

Comments

This step covers data quality checking as an informative aspect of vaccine administration

PreCondition

Order is placed for MMRV vaccine.

PostCondition

The MMRV vaccination route has failed to be recorded as 'oral' in the EMR.

Test Objectives

Record Vaccine Administration: The EHR or other clinical software system records information about each vaccine administered.  The EHR records this information as structured data elements, including, at a minimum: date administered, administering clinician, site of administration (e.g., left arm), immunization type, product, lot number, manufacturer, Vaccine Information Statement date, and quantity of vaccine/dose size.

Sample of data quality checking for vaccine route.

Evaluation Criteria

The EMR prevents the user for entering 'Oral' as a route for the the MMRV vaccine.

Notes to Testers

No Note

3.1.8. Record MMRV Vaccine administration

Test Step Type: SUT_MANUAL
The provider documents in the EMR all attributes associated with the new vaccine administration.

Test Story

Description

 

 

The nurse administers the the MMRV vaccine
• Documents all required information for each vaccine

 

 

Comments

No Comments

PreCondition

Order is placed for MMRV vaccine.

PostCondition

The MMRV vaccination is recorded in the EMR.

Test Objectives

Record Vaccine Administration: The EHR or other clinical software system records information about each vaccine administered.  The EHR records this information as structured data elements, including, at a minimum: date administered, administering clinician, site of administration (e.g., left arm), immunization type, product, lot number, manufacturer, Vaccine Information Statement date, and quantity of vaccine/dose size.

Evaluation Criteria

EMR Records the following vaccine administration information:

Entered BY Sandra Molina
Ordering Provider Frank Smith
Entering Organization Shoreline Pediatrics
Vaccine Event information source New immunization record (NIP001 00)
Order Value/Text for Vaccine Type  measles, mumps, rubella, and varicella virus vaccine (CVX 94 ), ProQuad (NDC 00006-4999-00)
Date/Time Vaccine  was recorded Current Date
Entered BY Sandra Molina
Ordering Provider Frank Smith
Entering Organization Shoreline Pediatrics
Vaccine Event information source New immunization record (NIP001 00)
Date/Time of Start of Administration Current Date
Vaccine Administered measles, mumps, rubella, and varicella virus vaccine (CVX 94 ),
ProQuad (NDC 00006-4999-00)
Dose Number 2
Doses in Series 2
Administered Amount (of Vaccine) 0.5
Administered Units (of Measure) mL
Administration Notes  
Administering Provider Sandra Molina
Administered-at Location 400 Shoreline Drive, Stamford Connecticut 06901
Lot Number 7W87V3687
Substance Expiration Date 7/15/2015
Substance Manufacturer Name Merck Sharp & Dohme Corp (MVX MSD)
Completion Status CP
Route of Administration Subcutaneous (NCIT C38299, HL70162: SC)
Administration Site Left Deltoid (HL70162 LD)
VFC Eligibility No

Notes to Testers

No Note

3.2. Juan Marcel Gonzales, Enter Orders and Immunizations

Orders and Immunization events, non-administrations, and alerts presented for current visit.

Test Story

Description
No Description

Comments
No Comments

PreCondition
No PreCondition

PostCondition
No PostCondition

Test Objectives
No Test Objectives

Evaluation Criteria
No evaluation criteria

Notes to Testers
No Note

3.2.1. Order intranasal, live virus influenza vaccine and view asthma contraindication

Test Step Type: SUT_MANUAL
Selects selects to order intranasal, live virus influenza vaccine and views information about patient asthma problem which is a contraindication to the intranasal vaccine.

Test Story

Description

The physician accesses the record for Juan Marcel Gonzales and:

• Orders administration of Influenza vaccine (intranasal, live virus vaccine)

• Receives notification the patient has asthma, a relative contraindication for intranasal influenza vaccine

Comments

No Comments

PreCondition

Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR.

PostCondition

User notified of history of contraindication tto nfluenza virus vaccine, live, attenuated, for intranasal use (CVX 111)
of asthma on problem list. Order is changed to Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161)
.

Test Objectives

Modify Antigen Recommendations Based on Active Diagnoses: The system notifies the provider of any conflicts between recommended vaccines in the updated forecast and the patient’s current or historical diagnoses.

Enter Vaccination Order: The EHR or other clinical software system allows providers to order immunizations for a patient using filters for type of vaccine, including combination vaccines.

Evaluation Criteria

EMR Records the following order information and Alert:

Entered BY Sandra Molina
Ordering Provider Frank Smith
Entering Organization Shoreline Pediatrics
Vaccine Event information source New immunization record (NIP001 00)
Value/Text for Vaccine Type  influenza virus vaccine, live, attenuated, for intranasal use (CVX 111)
Date/Time Vaccine Refusal was recorded Current Date
Alert Notification the patient has asthma, a relative contraindication for intranasal influenza vaccine.

The Provider changes the order to:

Vaccine Type:   Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161)

Notes to Testers

No Note

3.2.2. Orders administration of Hepatitis B vaccine

Test Step Type: SUT_MANUAL
The provider orders a Hepatitis B vaccine (dose 3).

Test Story

Description

As indicated by the vaccine forecast, the third Hepatitis B is overdue, and is ordered.

Comments

No Comments

PreCondition

Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. Vaccine forecast reviewed.

PostCondition

Hepatitis B vaccine is ordered for the patient.

Test Objectives

Enter Vaccination Order: The EHR or other clinical software system allows providers to order immunizations for a patient using filters for type of vaccine, including combination vaccines.

Evaluation Criteria

EMR Records the following order information and Alert:

Entered BY Sandra Molina
Ordering Provider Frank Smith
Entering Organization Shoreline Pediatrics
Vaccine Event information source New immunization record (NIP001 00)
Order Value/Text for Vaccine Type  hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08)
Date/Time Vaccine  was recorded Current Date

Notes to Testers

No Note

3.2.3. Orders administration of DTaP vaccine and alerted that the dose is too early

Test Step Type: SUT_MANUAL
The provider orders a DTaP vaccine (dose 5). The EMR provides an alert that the vaccine dose is too early.

Test Story

Description

  The fifth DTaP is ordered, and the provider is notified that the dose is too early.

Comments

No Comments

PreCondition

Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. Vaccine forecast is available in the EMR.

PostCondition

DTaP vaccine is ordered for the patient, and provider is notified that the dose is too early.

Test Objectives

Receive Dose Not Indicated Alert for Single Vaccine Order: The EHR or other clinical software system notifies the provider in instances when there are single or combination vaccine orders that are inconsistent with the expected timing intervals included in the vaccine forecast. Inconsistencies include suggestion of different date(s) for ordering the vaccine(s) or indication the vaccine(s) is/are no longer required.

Enter Vaccination Order: The EHR or other clinical software system allows providers to order immunizations for a patient using filters for type of vaccine, including combination vaccines.

Evaluation Criteria

EMR Records the following order information and Alert:

Entered BY Sandra Molina
Ordering Provider Frank Smith
Entering Organization Shoreline Pediatrics
Vaccine Event information source New immunization record (NIP001 00)
Value/Text for Vaccine Type  diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)
Date/Time Vaccine order was recorded Current Date
Alert Notification that the dose is too early

Notes to Testers

No Note

3.2.4. Records Hepatitis B Vaccine lot number with expired lot alert

Test Step Type: SUT_MANUAL
The provider records the vaccine administration lot number in the EMR and is alerted of the expired lot.

Test Story

Description

The nurse documents administration lot number for the Hepatitis B vaccine
• Is prevented from ordering the Hepatitis B lot as it has expired
• Documents administration from a different lot that is not expired
 

Comments

PreCondition

Order is placed for Hepatitis B vaccine.

PostCondition

The provider has been notified of the expired Hepatitis B vaccination lot. Documentation of a lot to be administered that is not expired is recorded in the EMR.

Test Objectives

Notify of Vaccine Dose Expiration: The EHR or other clinical software system notifies the provider administering a vaccine if the dose chosen for administration is expired.

Evaluation Criteria

EMR Records the following order information and Alert:

Entered BY Sandra Molina
Ordering Provider Frank Smith
Entering Organization Shoreline Pediatrics
Vaccine Event information source New immunization record (NIP001 00)
Date/Time of Start of Administration Current Date
Vaccine Administered hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08)
ENGERIX-B (NDC 58160-0820-11)
Lot Number (Expired) 6332FK18
Substance Expiration Date (Expired) 6/15/2015
Substance Manufacturer Name GlaxoSmithKline Biologicals SA (MVX SKB)
Alert Alerts user to expired lot

Notes to Testers

No Note

3.2.5. Record Hepatitis B Vaccine administration

Test Step Type: SUT_MANUAL
The EMR is able to document all attributes associated with the new vaccine administration.

Test Story

Description

 

 

The nurse administers the the Hepatitis B vaccine
• Documents all required information for the vaccine

 

 

Comments

No Comments

PreCondition

Order is placed for Hepatitis B vaccine.

PostCondition

The Hepatitis B vaccination is recorded in the EMR.

Test Objectives

Record Vaccine Administration: The EHR or other clinical software system records information about each vaccine administered.  The EHR records this information as structured data elements, including, at a minimum: date administered, administering clinician, site of administration (e.g., left arm), immunization type, product, lot number, manufacturer, Vaccine Information Statement date, and quantity of vaccine/dose size.

Evaluation Criteria

EMR Records the following vaccine administration information:

Entered BY Sandra Molina
Ordering Provider Frank Smith
Entering Organization Shoreline Pediatrics
Vaccine Event information source New immunization record (NIP001 00)
Date/Time of Start of Administration Current Date
Vaccine Administered hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08)
ENGERIX-B (NDC 58160-0820-11)
Dose Number 3  
Doses in Series 3
Administered Amount (of Vaccine) 0.5
Administered Units (of Measure) mL
Administration Notes  
Administering Provider Sandra Molina
Administered-at Location 400 Shoreline Drive, Stamford Connecticut 06901
Lot Number 6332FK26
Substance Expiration Date 8/25/2015
Substance Manufacturer Name GlaxoSmithKline Biologicals SA (MVX SKB)
Completion Status CP
Route of Administration Intramuscular (NCIT C28161, HL70162: IM)
Administration Site Left Deltoid (HL70162 LD)
VFC Eligibility No

Notes to Testers

No Note

3.2.6. Records Influenza Vaccine administration with VFC eligibility checking

Test Step Type: SUT_MANUAL
The provider records the vaccine administration from a VFC source and alerted that the patient is not VFC eligible.

Test Story

Description

The nurse documents administration for the inactivated influenza vaccine from a VFC source
• Is alerted that the patient is not eligible for VFC
• Orders a different non-VFC lot of inactivated influenza vaccine
 

Comments

This step covers data quality checking as an informative aspect of vaccine administration

PreCondition

Order is placed for inactivated influenza vaccine.

PostCondition

The user is notified of vaccine dose ineligibility.

Test Objectives

Notify of Vaccine Dose Ineligibility: The EHR or other clinical software system provides a method for alerting a provider if a vaccine is selected for a patient who is not eligible for the inventory item selected.

Evaluation Criteria

The provider documents a VFC lot to be administered in the EMR. Once notified that the patient is not eligible for the VFC, the a non-VFC lot is selected.

Entered BY Sandra Molina
Ordering Provider Frank Smith
Entering Organization Shoreline Pediatrics
Vaccine Event information source New immunization record (NIP001 00)
Value/Text for Vaccine Type  Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161), FLUZONE QUADRIVALENT (NDC 49281-0514-25)
Date/Time of Start of Administration Current Date
Vaccine Administered Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161), FLUZONE QUADRIVALENT (NDC 49281-0514-25)
VFC lot (not administered) D8043IN8422
Substance Expiration Date 8/15/2015
Substance Manufacturer Name Sanofi Pasteur (MVX PMC)
Alert Patient is not VFC Eligible

The Provider selects a non-VFC Lot:

Vaccine Lot # (administered):  D8043IN8855
Vaccine Expiration Date: 8/25/2015



Notes to Testers

No Note

3.2.7. Record Influenza Vaccine administration for Juan Marcel Gonzales

Test Step Type: SUT_MANUAL
The EMR is able to document all attributes associated with the new vaccine administration.

Test Story

Description

 

 

The nurse administers the  inactivated influenza vaccine
• Documents all required information for each vaccine

 

 

Comments

No Comments

PreCondition

Order is placed for  inactivated influenza vaccine.

PostCondition

The  inactivated influenza vaccine administration is recorded in the EMR.

Test Objectives

Record Vaccine Administration: The EHR or other clinical software system records information about each vaccine administered.  The EHR records this information as structured data elements, including, at a minimum: date administered, administering clinician, site of administration (e.g., left arm), immunization type, product, lot number, manufacturer, Vaccine Information Statement date, and quantity of vaccine/dose size.

Evaluation Criteria

EMR Records the following vaccine administration information:

Entered BY Sandra Molina
Ordering Provider Frank Smith
Entering Organization Shoreline Pediatrics
Vaccine Event information source (Administration Notes) New immunization record (NIP001 00)
Value/Text for Vaccine Type  Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161), FLUZONE QUADRIVALENT (NDC 49281-0514-25)
Date/Time of Start of Administration Current Date
Vaccine Administered Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161), FLUZONE QUADRIVALENT (NDC 49281-0514-25)
Administered Amount (of Vaccine) 0.25
Administered Units (of Measure) mL
Administering Provider Sandra Molina
Administered-at Location 400 Shoreline Drive, Stamford Connecticut 06901
Lot Number D8043IN8855
Substance Expiration Date 8/25/2015
Substance Manufacturer Name Sanofi Pasteur (MVX PMC)
Completion Status CP
Route of Administration Intramuscular (NCIT C28161, HL70162: IM)
Administration Site Left Thigh (HL7 LT)
VFC Eligibility No

Notes to Testers

No Note

3.3. Mariela Gonzales Morales, Enter Orders and Immunizations

Orders and Immunization events, non-administrations, and alerts presented for current visit.

Test Story

Description
No Description

Comments
No Comments

PreCondition
No PreCondition

PostCondition
No PostCondition

Test Objectives
No Test Objectives

Evaluation Criteria
No evaluation criteria

Notes to Testers
No Note

3.3.1. Enters a deferral for the vaccines due

Test Step Type: SUT_MANUAL
Enters a deferral for vaccines due (Hepatitis B, DTaP, Hib, Pneumococcal conjugate (PCV13) and Rotavirus) due to medical reason, indicating low grade fever, and defers for 1 month.

Test Story

Description

The physician accesses the record for Mariela Gonzales Morales and:
• Enters a deferral for the vaccines due (Hepatitis B, DTaP, Hib, Pneumococcal conjugate (PCV13) and Rotavirus) due to medical reason, indicating low grade fever, and defers for 1 month

Comments

No Comment

PreCondition

Prior Immunization History loaded and reconciled from the Immunization Registry.  Vaccine forecast is available in the EMR indicating 5 vaccines are due: Hepatitis B, DTaP, Hib, Pneumococcal conjugate (PCV13) and Rotavirus

PostCondition

Vaccine deferral is recorded indicating the medical reason of low grade fever

Test Objectives

Record Vaccine Administration Deferral: The EHR or other clinical software system allows a user to enter a reason or reasons why a specific immunization was not given to a patient (e.g., due to contraindication, refusal, etc.).  The system also stores that information in a structured way so it can be reported and analyzed as needed.

Evaluation Criteria

 EMR Records the following vaccine administration information:

Entered BY Sandra Molina
Ordering Provider Frank Smith
Entering Organization Shoreline Pediatrics
Vaccine Event information source New immunization record (NIP001 00)
Value/Text for Vaccine Type  hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08)
diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)
Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)
 pneumococcal conjugate vaccine, 13 valent (CVX 133)
rotavirus, live, monovalent vaccine (CVX 119)
Date/Time Vaccine not administered was recorded Current Date
Alert contraindication of fever
Substance/Treatment Deferral Start Date:Vaccination contraindication/precaution effective date (30946-8 LOINC) Current Date
Substance/Treatment Deferral End Date/Vaccination temporary contraindication/precaution expiration date (30944-3 LOINC) : Current Date +30 Days
Substance/Treatment Deferral Contraindication:  Vaccination contraindication/precaution (30945-0 LOINC): current fever with moderate-to-severe illness (PHVS_VaccinationContraindication_IIS - VXC23)
Completion Status:  NA
Date/Time Vaccine Deferral was recorded:  Current Date

Notes to Testers

No Note

4. Transmit Immunization Report

This test will consist of generating a Vaccine Update (VXU-Z22) report to the registry for three of the test patients, including updates for vaccines not given. NOTE: There is no Immunization Report in this test plan for Juana Maria Gonzales.

4.1. Juana Mariana Gonzales Transmit Immunization Report

Send the Immunization Report to the Immunization Registry (VXU/Z22) for Juana Mariana Gonzales.

Test Story

Description
Following the vaccinations given during the visit, the EMR transmits an Immunization report to the Immunization Registry using the VXU/Z22. The Vaccination report includes all newly administered vaccines. The report should include vaccines incorrectly recorded in the IIS. The report MAY send the immunizations that the EMR imported from the IIS.

Comments
The Report must include all newly administered vaccines in any order. the report may also include the corrected information where the EMR has different information than the IIS, and may also include the information imported from the IIS.

PreCondition
The vaccines for the visit have been administered.

PostCondition
No PostCondition

Test Objectives
Transmit Standard Patient Immunization History Report: The EHR or other clinical software system directly or indirectly through an intermediary creates and transmits a report of a patient's immunization history to public health immunization registries.

Evaluation Criteria
No evaluation criteria

Notes to Testers
No Note

4.1.1. Transmit the immunization report to the Immunization Registry

Test Step Type: SUT_INITIATOR
The EMR send the Immunization Report to the Immunization Registry (VXU/Z22) for updated vaccination information from the visit. This includes all newly administered vaccines and may include historical information updated in the EMR during the visit.

Test Story

Description

Following the vaccinations given during the visit, the EMR transmits an Immunization report to the Immunization Registry using the VXU/Z22. The Vaccination report includes all newly administered vaccines. The report should include vaccines incorrectly recorded in the IIS. The report MAY send the immunizations that the EMR imported from the IIS.

Comments

The Report must include all newly administered vaccines in any order. the report may also include the corrected information where the EMR has different information than the IIS, and may also include the information imported from the IIS.

PreCondition

The vaccines for the visit have been administered.

PostCondition

The Immunization Report has been transmitted to the IIS using a valid Z22 VXU in accordance with the test data correctly and without omission.

Test Objectives

Transmit Standard Patient Immunization History Report: The EHR or other clinical software system directly or indirectly through an intermediary creates and transmits a report of a patient's immunization history to public health immunization registries.

Evaluation Criteria

The VXU/Z22 message passes validation using the NIST Immunization VXU Validation Tool (Z22) (context-free). The content of the message correctly reflects the test data (context-based) in accordance with the Test Data Specification and the Message Content.

Notes to Testers

No Note

Message Contents

MSH
Location Data Element Data Categorization
MSH.1 Field Separator |
MSH.2 Encoding Characters ^~\&
MSH.3 Sending Application
MSH.3.1 Namespace ID Test EHR Application
MSH.3.2 Universal ID
MSH.3.3 Universal ID Type
MSH.4 Sending Facility
MSH.4.1 Namespace ID X68
MSH.4.2 Universal ID
MSH.4.3 Universal ID Type
MSH.5 Receiving Application
MSH.5.1 Namespace ID
MSH.5.2 Universal ID
MSH.5.3 Universal ID Type
MSH.6 Receiving Facility
MSH.6.1 Namespace ID NIST Test Iz Reg
MSH.6.2 Universal ID
MSH.6.3 Universal ID Type
MSH.7 Date/Time Of Message
MSH.7.1 Time 20120701082240-0500
MSH.9 Message Type
MSH.9.1 Message Code VXU
MSH.9.2 Trigger Event V04
MSH.9.3 Message Structure VXU_V04
MSH.10 Message Control ID NIST-IZ-001.00
MSH.11 Processing ID
MSH.11.1 Processing ID P
MSH.12 Version ID
MSH.12.1 Version ID 2.5.1
MSH.15 Accept Acknowledgment Type ER
MSH.16 Application Acknowledgment Type AL
MSH.21 Message Profile Identifier
MSH.21.1 Entity Identifier Z22
MSH.21.2 Namespace ID CDCPHINVS
MSH.21.3 Universal ID
MSH.21.4 Universal ID Type
MSH.22 Sending Responsible Organization
MSH.22.1 Organization Name
MSH.22.6 Assigning Authority
MSH.22.6.1 Namespace ID
MSH.22.6.2 Universal ID
MSH.22.6.3 Universal ID Type
MSH.22.7 Identifier Type Code
MSH.22.10 Organization Identifier
MSH.23 Receiving Responsible Organization
MSH.23.1 Organization Name
MSH.23.6 Assigning Authority
MSH.23.6.1 Namespace ID
MSH.23.6.2 Universal ID
MSH.23.6.3 Universal ID Type
MSH.23.7 Identifier Type Code
MSH.23.10 Organization Identifier

PID
Location Data Element Data Categorization
PID.1 Set ID - PID 1
PID.3 Patient Identifier List
PID.3.1 ID Number 123456
PID.3.3 Check Digit Scheme
PID.3.4 Assigning Authority
PID.3.4.1 Namespace ID MYEHR
PID.3.4.2 Universal ID
PID.3.4.3 Universal ID Type
PID.3.5 Identifier Type Code MR
PID.3 Patient Identifier List
PID.3.1 ID Number 987633
PID.3.3 Check Digit Scheme
PID.3.4 Assigning Authority
PID.3.4.1 Namespace ID MYIIS
PID.3.4.2 Universal ID
PID.3.4.3 Universal ID Type
PID.3.5 Identifier Type Code SR
PID.5 Patient Name
PID.5.1 Family Name
PID.5.1.1 Surname Gonzales Test Case Fixed
PID.5.1.2 Own Surname Prefix
PID.5.1.3 Own Surname
PID.5.1.4 Surname Prefix From Partner/Spouse
PID.5.1.5 Surname From Partner/Spouse
PID.5.2 Given Name Juana Test Case Fixed
PID.5.3 Second and Further Given Names or Initials Thereof Mariana Test Case Fixed
PID.5.7 Name Type Code L Test Case Fixed
PID.6 Mother's Maiden Name
PID.6.1 Family Name
PID.6.1.1 Surname Acosta Test Case Fixed
PID.6.1.2 Own Surname Prefix
PID.6.1.3 Own Surname
PID.6.1.4 Surname Prefix From Partner/Spouse
PID.6.1.5 Surname From Partner/Spouse
PID.6.7 Name Type Code M Test Case Fixed
PID.7 Date/Time of Birth
PID.7.1 Time 200912231105 Test Case Fixed
PID.8 Administrative Sex F Test Case Fixed
PID.10 Race
PID.10.1 Identifier 2131-1 Test Case Fixed
PID.10.2 Text Other Race Test Case Fixed
PID.10.3 Name of Coding System HL70005 Test Case Fixed
PID.10.5 Alternate Text
PID.10.6 Name of Alternate Coding System
PID.11 Patient Address
PID.11.1 Street Address
PID.11.1.1 Street or Mailing Address 4345 Standish Way Test Case Fixed
PID.11.1.2 Street Name
PID.11.1.3 Dwelling Number
PID.11.2 Other Designation
PID.11.3 City Stamford Test Case Fixed
PID.11.4 State or Province CT Test Case Fixed
PID.11.5 Zip or Postal Code 06903 Test Case Fixed
PID.11.6 Country USA Test Case Fixed
PID.11.7 Address Type L Test Case Fixed
PID.11 Patient Address
PID.11.1 Street Address
PID.11.1.1 Street or Mailing Address 325 Shorline Drive
PID.11.1.2 Street Name
PID.11.1.3 Dwelling Number
PID.11.2 Other Designation
PID.11.3 City Stamford
PID.11.4 State or Province CT Test Case Fixed
PID.11.5 Zip or Postal Code 06901
PID.11.6 Country
PID.11.7 Address Type BDL Test Case Fixed
PID.13 Phone Number - Home
PID.13.2 Telecommunication Use Code PRN Test Case Fixed
PID.13.3 Telecommunication Equipment Type PH Test Case Fixed
PID.13.4 Email Address
PID.13.6 Area/City Code 203 Test Case Fixed
PID.13.7 Local Number 5551212 Test Case Fixed
PID.22 Ethnic Group
PID.22.1 Identifier 2135-2 Test Case Fixed
PID.22.2 Text Hispanic or Latino Test Case Fixed
PID.22.3 Name of Coding System CDCREC Test Case Fixed
PID.22.5 Alternate Text
PID.22.6 Name of Alternate Coding System
PID.24 Multiple Birth Indicator
PID.25 Birth Order
PID.29 Patient Death Date and Time
PID.29.1 Time
PID.30 Patient Death Indicator

PD1
Location Data Element Data Categorization
PD1.11 Publicity Code
PD1.11.1 Identifier 02
PD1.11.2 Text Reminder/Recall - any method
PD1.11.3 Name of Coding System HL70215
PD1.11.5 Alternate Text
PD1.11.6 Name of Alternate Coding System
PD1.12 Protection Indicator
PD1.13 Protection Indicator Effective Date
PD1.16 Immunization Registry Status A
PD1.17 Immunization Registry Status Effective Date 20120701
PD1.18 Publicity Code Effective Date 20120701

NK1
Location Data Element Data Categorization
NK1.1 Set ID - NK1 1
NK1.2 Name
NK1.2.1 Family Name
NK1.2.1.1 Surname Gonzales
NK1.2.1.2 Own Surname Prefix
NK1.2.1.3 Own Surname
NK1.2.1.4 Surname Prefix From Partner/Spouse
NK1.2.1.5 Surname From Partner/Spouse
NK1.2.2 Given Name Joanna Test Case Fixed
NK1.2.3 Second and Further Given Names or Initials Thereof Merida Test Case Fixed
NK1.2.7 Name Type Code L Test Case Fixed
NK1.3 Relationship
NK1.3.1 Identifier GRP Test Case Fixed
NK1.3.2 Text Grandparent Test Case Fixed
NK1.3.3 Name of Coding System HL70063 Test Case Fixed
NK1.3.5 Alternate Text
NK1.3.6 Name of Alternate Coding System
NK1.4 Address
NK1.4.1 Street Address
NK1.4.1.1 Street or Mailing Address 4345 Standish Way Test Case Fixed
NK1.4.1.2 Street Name
NK1.4.1.3 Dwelling Number
NK1.4.2 Other Designation
NK1.4.3 City Stamford Test Case Fixed
NK1.4.4 State or Province CT Test Case Fixed
NK1.4.5 Zip or Postal Code 06901 Test Case Fixed
NK1.4.6 Country
NK1.4.7 Address Type L Test Case Fixed
NK1.5 Phone Number
NK1.5.2 Telecommunication Use Code PRN Test Case Fixed
NK1.5.3 Telecommunication Equipment Type PH Test Case Fixed
NK1.5.4 Email Address
NK1.5.6 Area/City Code 203 Test Case Fixed
NK1.5.7 Local Number 5551212 Test Case Fixed

ORC[*]
ORC - 1
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Sirtis
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name Lisa
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Carter
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Jane
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier SH
ORC.17.2 Text Shoreline Hospital
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 2
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Molina
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name Sandra
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Smith
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Frank
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier SP
ORC.17.2 Text Shoreline Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 3
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 4
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 5
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 6
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L Test Case Fixed
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 7
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 8
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Molina
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name Sandra
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier SP
ORC.17.2 Text Shoreline Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 9
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 10
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 11
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 12
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 13
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 14
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 15
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Molina
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name Sandra
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier SP
ORC.17.2 Text Shoreline Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 16
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 9999
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Molina
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name Sandra
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Smith
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Frank
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier SP
ORC.17.2 Text Shoreline Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 17
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 18
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 19
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 20
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 21
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 22
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 23
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 24
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 25
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 26
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Molina
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name Sandra
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Ricci
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Gina
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier SP
ORC.17.2 Text Shoreline Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 27
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Molina Test Case Fixed
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name Sandra Test Case Fixed
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Smith Test Case Fixed
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Frank Test Case Fixed
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L Test Case Fixed
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier SP
ORC.17.2 Text Shoreline Pediatrics Test Case Fixed
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 28
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 29
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 30
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Smith
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name F
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 31
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Smith
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name F
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 32
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Smith
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name F
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 33
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Molina Test Case Fixed
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name Sandra Test Case Fixed
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Smith Test Case Fixed
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Frank Test Case Fixed
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L Test Case Fixed
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier SP
ORC.17.2 Text Shoreline Pediatrics Test Case Fixed
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

RXA[*]
RXA - 1
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20091123
RXA.5 Administered Code
RXA.5.1 Identifier 08
RXA.5.2 Text hepatitis B vaccine, pediatric or pediatric/adolescent dosage
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text ENGERIX-B
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Sirtis
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name Lisa
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 6332FK33
RXA.16 Substance Expiration Date
RXA.16.1 Time 20101214
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier SKB
RXA.17.2 Text GlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 2
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100115
RXA.5 Administered Code
RXA.5.1 Identifier 45
RXA.5.2 Text hepatitis B vaccine, unspecified formulation
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text ENGERIX-B
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 01
RXA.9.2 Text Historical Immunization
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Molina
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name Sandra
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 6352FK1
RXA.16 Substance Expiration Date
RXA.16.1 Time 20101001
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier SKB
RXA.17.2 Text GlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 3
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20101030
RXA.5 Administered Code
RXA.5.1 Identifier 08
RXA.5.2 Text hepatitis B vaccine, pediatric or pediatric/adolescent dosage
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text ENGERIX-B
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 6352FK24
RXA.16 Substance Expiration Date
RXA.16.1 Time 20120831
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier SKB
RXA.17.2 Text GlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 4
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100122
RXA.5 Administered Code
RXA.5.1 Identifier 107
RXA.5.2 Text diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text DAPTACEL
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D409QS2341
RXA.16 Substance Expiration Date
RXA.16.1 Time 20111130
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi Pasteur Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 5
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100323
RXA.5 Administered Code
RXA.5.1 Identifier 106
RXA.5.2 Text diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text DAPTACEL
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D409QS2433
RXA.16 Substance Expiration Date
RXA.16.1 Time 20110904
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi Pasteur Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 6
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100522
RXA.5 Administered Code
RXA.5.1 Identifier 106
RXA.5.2 Text diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text DAPTACEL
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D409QS3255
RXA.16 Substance Expiration Date
RXA.16.1 Time 20101201
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi Pasteur Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 7
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20110221
RXA.5 Administered Code
RXA.5.1 Identifier 106
RXA.5.2 Text diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text DAPTACEL
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D409QS249
RXA.16 Substance Expiration Date
RXA.16.1 Time 20110301
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi Pasteur Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 8
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20140831
RXA.5 Administered Code
RXA.5.1 Identifier 106
RXA.5.2 Text diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text DAPTACEL
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 02
RXA.9.2 Text Historical information - from other provider
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Casera
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name Linda
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D643QS8243
RXA.16 Substance Expiration Date
RXA.16.1 Time 20140901
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi Pasteur Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 9
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100122
RXA.5 Administered Code
RXA.5.1 Identifier 49
RXA.5.2 Text Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text PedvaxHIB
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 7M54K9245
RXA.16 Substance Expiration Date
RXA.16.1 Time 20100324
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier MSD
RXA.17.2 Text Merck Sharp \T\ Dohme Corp
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 10
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100323
RXA.5 Administered Code
RXA.5.1 Identifier 49
RXA.5.2 Text Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text PedvaxHIB
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 7M55K3342
RXA.16 Substance Expiration Date
RXA.16.1 Time 20101030
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier MSD
RXA.17.2 Text Merck Sharp \T\ Dohme Corp
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 11
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100522
RXA.5 Administered Code
RXA.5.1 Identifier 49
RXA.5.2 Text Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text PedvaxHIB
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 7M75K4566
RXA.16 Substance Expiration Date
RXA.16.1 Time 20100523
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier MSD
RXA.17.2 Text Merck Sharp \T\ Dohme Corp
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 12
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20110221
RXA.5 Administered Code
RXA.5.1 Identifier 49
RXA.5.2 Text Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text PedvaxHIB
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 7M53K5534
RXA.16 Substance Expiration Date
RXA.16.1 Time 20110222
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier MSD
RXA.17.2 Text Merck Sharp \T\ Dohme Corp
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 13
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100122
RXA.5 Administered Code
RXA.5.1 Identifier 10
RXA.5.2 Text poliovirus vaccine, inactivated
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text IPOL
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D333PV2431
RXA.16 Substance Expiration Date
RXA.16.1 Time 20101004
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi Pasteur Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 14
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100323
RXA.5 Administered Code
RXA.5.1 Identifier 10
RXA.5.2 Text poliovirus vaccine, inactivated
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text IPOL
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D333PV4344
RXA.16 Substance Expiration Date
RXA.16.1 Time 20100323
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi Pasteur Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 15
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20110221
RXA.5 Administered Code
RXA.5.1 Identifier 10
RXA.5.2 Text poliovirus vaccine, inactivated
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text IPOL
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 02
RXA.9.2 Text Historical information - from other provider
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Casera
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name Linda
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D335PV9644
RXA.16 Substance Expiration Date
RXA.16.1 Time 20110222
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi Pasteur Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 16
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20150519
RXA.5 Administered Code
RXA.5.1 Identifier 10
RXA.5.2 Text poliovirus vaccine, inactivated
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text
RXA.5.6 Name of Alternate Coding System
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier
RXA.9.2 Text
RXA.9.3 Name of Coding System
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number
RXA.16 Substance Expiration Date
RXA.16.1 Time
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier
RXA.17.2 Text
RXA.17.3 Name of Coding System
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier 00
RXA.18.2 Text Parental decision
RXA.18.3 Name of Coding System NIP002
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status RE
RXA.21 Action Code - RXA A

RXA - 17
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100121
RXA.5 Administered Code
RXA.5.1 Identifier 133
RXA.5.2 Text pneumococcal conjugate vaccine, 13 valent
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text PREVNAR 13
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number P243V3281
RXA.16 Substance Expiration Date
RXA.16.1 Time 20100130
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PFR
RXA.17.2 Text Pfizer, Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 18
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100323
RXA.5 Administered Code
RXA.5.1 Identifier 133
RXA.5.2 Text pneumococcal conjugate vaccine, 13 valent
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text PREVNAR 13
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number P343V8321
RXA.16 Substance Expiration Date
RXA.16.1 Time 20100330
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PFR
RXA.17.2 Text Pfizer, Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 19
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100522
RXA.5 Administered Code
RXA.5.1 Identifier 133
RXA.5.2 Text pneumococcal conjugate vaccine, 13 valent
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text PREVNAR 13
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number P853V2164
RXA.16 Substance Expiration Date
RXA.16.1 Time 20100830
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PFR
RXA.17.2 Text Pfizer, Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 20
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20110221
RXA.5 Administered Code
RXA.5.1 Identifier 133
RXA.5.2 Text pneumococcal conjugate vaccine, 13 valent
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text PREVNAR 13
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number P853V58532
RXA.16 Substance Expiration Date
RXA.16.1 Time 20110418
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PFR
RXA.17.2 Text Pfizer, Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 21
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100122
RXA.5 Administered Code
RXA.5.1 Identifier 119
RXA.5.2 Text rotavirus, live, monovalent vaccine
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text ROTARIX
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 6359RV533
RXA.16 Substance Expiration Date
RXA.16.1 Time 20100215
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier SKB
RXA.17.2 Text GlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 22
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100323
RXA.5 Administered Code
RXA.5.1 Identifier 119
RXA.5.2 Text rotavirus, live, monovalent vaccine
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text ROTARIX
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 6359RV932
RXA.16 Substance Expiration Date
RXA.16.1 Time 20100510
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier SKB
RXA.17.2 Text GlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 23
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100925
RXA.5 Administered Code
RXA.5.1 Identifier 161
RXA.5.2 Text Influenza, injectable,quadrivalent, preservative free, pediatric
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text FLUZONE QUADRIVALENT
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D8043IN8734
RXA.16 Substance Expiration Date
RXA.16.1 Time 20110312
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 24
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20101027
RXA.5 Administered Code
RXA.5.1 Identifier 161
RXA.5.2 Text Influenza, injectable,quadrivalent, preservative free, pediatric
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text FLUZONE QUADRIVALENT
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D8043IN8734
RXA.16 Substance Expiration Date
RXA.16.1 Time 20110312
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 25
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20111002
RXA.5 Administered Code
RXA.5.1 Identifier 161
RXA.5.2 Text Influenza, injectable,quadrivalent, preservative free, pediatric
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text FLUZONE QUADRIVALENT
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D9334IN9333
RXA.16 Substance Expiration Date
RXA.16.1 Time 20120522
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 26
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20131015
RXA.5 Administered Code
RXA.5.1 Identifier 161
RXA.5.2 Text Influenza, injectable,quadrivalent, preservative free, pediatric
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text FLUZONE QUADRIVALENT
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 03
RXA.9.2 Text Historical information - from parents written record
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Ricci
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name Gina
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 8L4B3423
RXA.16 Substance Expiration Date
RXA.16.1 Time 20140701
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier MED
RXA.17.2 Text MedImmune, LLC
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 27
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20150715
RXA.5 Administered Code
RXA.5.1 Identifier 149 Test Case Fixed
RXA.5.2 Text influenza, live, intranasal, quadrivalent Test Case Fixed
RXA.5.3 Name of Coding System CVX Test Case Fixed
RXA.5.5 Alternate Text FluMist Quadrivalent Test Case Fixed
RXA.5.6 Name of Alternate Coding System NDC Test Case Fixed
RXA.6 Administered Amount 0.2 Test Case Fixed
RXA.7 Administered Units
RXA.7.1 Identifier mL Test Case Fixed
RXA.7.2 Text
RXA.7.3 Name of Coding System UCUM Test Case Fixed
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 00 Test Case Fixed
RXA.9.2 Text New immunization record Test Case Fixed
RXA.9.3 Name of Coding System NIP001 Test Case Fixed
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Molina Test Case Fixed
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name Sandra Test Case Fixed
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 8L4B3521 Test Case Fixed
RXA.16 Substance Expiration Date
RXA.16.1 Time 20150815 Test Case Fixed
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier MED Test Case Fixed
RXA.17.2 Text MedImmune,LLC Test Case Fixed
RXA.17.3 Name of Coding System MVX Test Case Fixed
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP Test Case Fixed
RXA.21 Action Code - RXA A

RXA - 28
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20121104
RXA.5 Administered Code
RXA.5.1 Identifier 149
RXA.5.2 Text influenza, live, intranasal, quadrivalent
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text FluMist Quadrivalent
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D9553IN2243
RXA.16 Substance Expiration Date
RXA.16.1 Time 20120430
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 29
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20111123
RXA.5 Administered Code
RXA.5.1 Identifier 83
RXA.5.2 Text hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text HAVRIX
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 6359RT33
RXA.16 Substance Expiration Date
RXA.16.1 Time 20120124
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier SKB
RXA.17.2 Text GlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 30
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20120523
RXA.5 Administered Code
RXA.5.1 Identifier 83
RXA.5.2 Text hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text HAVRIX
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 6359RT48
RXA.16 Substance Expiration Date
RXA.16.1 Time 20120911
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 31
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20101023
RXA.5 Administered Code
RXA.5.1 Identifier 94
RXA.5.2 Text measles, mumps, rubella, and varicella virus vaccine
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text ProQuad
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 01
RXA.9.2 Text historical
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 7W27V7491
RXA.16 Substance Expiration Date
RXA.16.1 Time 20101215
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier MSD
RXA.17.2 Text Merck Sharp \T\ Dohme Corp
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 32
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20121122
RXA.5 Administered Code
RXA.5.1 Identifier 94
RXA.5.2 Text measles, mumps, rubella, and varicella virus vaccine
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text ProQuad
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 7W87V3452
RXA.16 Substance Expiration Date
RXA.16.1 Time 20130413
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier MSD
RXA.17.2 Text Merck Sharp \T\ Dohme Corp
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 33
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20150715
RXA.5 Administered Code
RXA.5.1 Identifier 94 Test Case Fixed
RXA.5.2 Text measles, mumps, rubella, and varicella virus vaccine Test Case Fixed
RXA.5.3 Name of Coding System CVX Test Case Fixed
RXA.5.5 Alternate Text ProQuad Test Case Fixed
RXA.5.6 Name of Alternate Coding System NDC Test Case Fixed
RXA.6 Administered Amount 0.5 Test Case Fixed
RXA.7 Administered Units
RXA.7.1 Identifier mL Test Case Fixed
RXA.7.2 Text
RXA.7.3 Name of Coding System UCUM Test Case Fixed
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 00 Test Case Fixed
RXA.9.2 Text New immunization record Test Case Fixed
RXA.9.3 Name of Coding System NIP001 Test Case Fixed
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Molina Test Case Fixed
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name Sandra Test Case Fixed
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 7W87V3687 Test Case Fixed
RXA.16 Substance Expiration Date
RXA.16.1 Time 20150715 Test Case Fixed
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier MSD Test Case Fixed
RXA.17.2 Text Merck Sharp \T\ Dohme Corp Test Case Fixed
RXA.17.3 Name of Coding System MVX Test Case Fixed
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP Test Case Fixed
RXA.21 Action Code - RXA A

RXR[*]
RXR - 1
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 2
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier RT
RXR.2.2 Text Right Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 3
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 4
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 5
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier RT
RXR.2.2 Text Right Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 6
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 7
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 8
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 9
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier RT
RXR.2.2 Text Right Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 10
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 11
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier RT
RXR.2.2 Text Right Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 12
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 13
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C38299
RXR.1.2 Text SC
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text Subcutaneous
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 14
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C38299
RXR.1.2 Text SC
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text Subcutaneous
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 15
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C38299
RXR.1.2 Text SC
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text Subcutaneous
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 16
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 17
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C38299
RXR.1.2 Text SC
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text Subcutaneous
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 18
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier RT
RXR.2.2 Text Right Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 19
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 20
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 21
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier RT
RXR.2.2 Text Right Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 22
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 23
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier RT
RXR.2.2 Text Right Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 24
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 25
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C38284
RXR.1.2 Text Nasal
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text Nasal
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier BN
RXR.2.2 Text Bilateral Nares
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 26
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C38284 Test Case Fixed
RXR.1.2 Text Nasal Test Case Fixed
RXR.1.3 Name of Coding System NCIT Test Case Fixed
RXR.1.5 Alternate Text Nasal Test Case Fixed
RXR.1.6 Name of Alternate Coding System HL70162 Test Case Fixed
RXR.2 Administration Site
RXR.2.1 Identifier BN
RXR.2.2 Text Bilateral Nares
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 27
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 28
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier RD
RXR.2.2 Text Right Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 29
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 30
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C38299
RXR.1.2 Text Subcutaneous
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text Subcutaneous
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 31
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C38299
RXR.1.2 Text Subcutaneous
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text Subcutaneous
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 32
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C38299 Test Case Fixed
RXR.1.2 Text Subcutaneous Test Case Fixed
RXR.1.3 Name of Coding System NCIT Test Case Fixed
RXR.1.5 Alternate Text Subcutaneous Test Case Fixed
RXR.1.6 Name of Alternate Coding System HL70162 Test Case Fixed
RXR.2 Administration Site
RXR.2.1 Identifier LD Test Case Fixed
RXR.2.2 Text Left Deltoid Test Case Fixed
RXR.2.3 Name of Coding System HL70163 Test Case Fixed
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

OBX[*]
OBX - 1
Location Data Element Data Categorization
OBX.1 Set ID - OBX 21
OBX.2 Value Type CE
OBX.3 Observation Identifier
OBX.3.1 Identifier 31044-1
OBX.3.2 Text Reaction
OBX.3.3 Name of Coding System LN
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20100522
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 2
Location Data Element Data Categorization
OBX.1 Set ID - OBX 2
OBX.2 Value Type TS
OBX.3 Observation Identifier
OBX.3.1 Identifier 29768-9 Test Case Fixed
OBX.3.2 Text VIS Publication Date Test Case Fixed
OBX.3.3 Name of Coding System LN Test Case Fixed
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.5.1 Time 20140819
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 3
Location Data Element Data Categorization
OBX.1 Set ID - OBX 3
OBX.2 Value Type TS
OBX.3 Observation Identifier
OBX.3.1 Identifier 29769-7 Test Case Fixed
OBX.3.2 Text VIS Presentation Date Test Case Fixed
OBX.3.3 Name of Coding System LN Test Case Fixed
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.5.1 Time 20150715
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 4
Location Data Element Data Categorization
OBX.1 Set ID - OBX 1
OBX.2 Value Type CE
OBX.3 Observation Identifier
OBX.3.1 Identifier 64994-7 Test Case Fixed
OBX.3.2 Text vaccine fund pgm elig cat Test Case Fixed
OBX.3.3 Name of Coding System LN Test Case Fixed
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 5
Location Data Element Data Categorization
OBX.1 Set ID - OBX 2
OBX.2 Value Type TS
OBX.3 Observation Identifier
OBX.3.1 Identifier 29768-9 Test Case Fixed
OBX.3.2 Text VIS Publication Date Test Case Fixed
OBX.3.3 Name of Coding System LN Test Case Fixed
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.5.1 Time 20100521
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 6
Location Data Element Data Categorization
OBX.1 Set ID - OBX 3
OBX.2 Value Type TS
OBX.3 Observation Identifier
OBX.3.1 Identifier 29769-7 Test Case Fixed
OBX.3.2 Text VIS Presentation Date Test Case Fixed
OBX.3.3 Name of Coding System LN Test Case Fixed
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.5.1 Time 20150715
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 7
Location Data Element Data Categorization
OBX.1 Set ID - OBX 1
OBX.2 Value Type CE
OBX.3 Observation Identifier
OBX.3.1 Identifier 64994-7 Test Case Fixed
OBX.3.2 Text vaccine fund pgm elig cat Test Case Fixed
OBX.3.3 Name of Coding System LN Test Case Fixed
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

Location Data Element Data Categorization
MSH.1 Field Separator |
MSH.2 Encoding Characters ^~\&
MSH.3 Sending Application
MSH.3.1 Namespace ID Test EHR Application
MSH.3.2 Universal ID
MSH.3.3 Universal ID Type
MSH.4 Sending Facility
MSH.4.1 Namespace ID X68
MSH.4.2 Universal ID
MSH.4.3 Universal ID Type
MSH.5 Receiving Application
MSH.5.1 Namespace ID
MSH.5.2 Universal ID
MSH.5.3 Universal ID Type
MSH.6 Receiving Facility
MSH.6.1 Namespace ID NIST Test Iz Reg
MSH.6.2 Universal ID
MSH.6.3 Universal ID Type
MSH.7 Date/Time Of Message
MSH.7.1 Time 20120701082240-0500
MSH.9 Message Type
MSH.9.1 Message Code VXU
MSH.9.2 Trigger Event V04
MSH.9.3 Message Structure VXU_V04
MSH.10 Message Control ID NIST-IZ-001.00
MSH.11 Processing ID
MSH.11.1 Processing ID P
MSH.12 Version ID
MSH.12.1 Version ID 2.5.1
MSH.15 Accept Acknowledgment Type ER
MSH.16 Application Acknowledgment Type AL
MSH.21 Message Profile Identifier
MSH.21.1 Entity Identifier Z22
MSH.21.2 Namespace ID CDCPHINVS
MSH.21.3 Universal ID
MSH.21.4 Universal ID Type
MSH.22 Sending Responsible Organization
MSH.22.1 Organization Name
MSH.22.6 Assigning Authority
MSH.22.6.1 Namespace ID
MSH.22.6.2 Universal ID
MSH.22.6.3 Universal ID Type
MSH.22.7 Identifier Type Code
MSH.22.10 Organization Identifier
MSH.23 Receiving Responsible Organization
MSH.23.1 Organization Name
MSH.23.6 Assigning Authority
MSH.23.6.1 Namespace ID
MSH.23.6.2 Universal ID
MSH.23.6.3 Universal ID Type
MSH.23.7 Identifier Type Code
MSH.23.10 Organization Identifier

Location Data Element Data Categorization
PID.1 Set ID - PID 1
PID.3 Patient Identifier List
PID.3.1 ID Number 123456
PID.3.3 Check Digit Scheme
PID.3.4 Assigning Authority
PID.3.4.1 Namespace ID MYEHR
PID.3.4.2 Universal ID
PID.3.4.3 Universal ID Type
PID.3.5 Identifier Type Code MR
PID.3 Patient Identifier List
PID.3.1 ID Number 987633
PID.3.3 Check Digit Scheme
PID.3.4 Assigning Authority
PID.3.4.1 Namespace ID MYIIS
PID.3.4.2 Universal ID
PID.3.4.3 Universal ID Type
PID.3.5 Identifier Type Code SR
PID.5 Patient Name
PID.5.1 Family Name
PID.5.1.1 Surname Gonzales Test Case Fixed
PID.5.1.2 Own Surname Prefix
PID.5.1.3 Own Surname
PID.5.1.4 Surname Prefix From Partner/Spouse
PID.5.1.5 Surname From Partner/Spouse
PID.5.2 Given Name Juana Test Case Fixed
PID.5.3 Second and Further Given Names or Initials Thereof Mariana Test Case Fixed
PID.5.7 Name Type Code L Test Case Fixed
PID.6 Mother's Maiden Name
PID.6.1 Family Name
PID.6.1.1 Surname Acosta Test Case Fixed
PID.6.1.2 Own Surname Prefix
PID.6.1.3 Own Surname
PID.6.1.4 Surname Prefix From Partner/Spouse
PID.6.1.5 Surname From Partner/Spouse
PID.6.7 Name Type Code M Test Case Fixed
PID.7 Date/Time of Birth
PID.7.1 Time 200912231105 Test Case Fixed
PID.8 Administrative Sex F Test Case Fixed
PID.10 Race
PID.10.1 Identifier 2131-1 Test Case Fixed
PID.10.2 Text Other Race Test Case Fixed
PID.10.3 Name of Coding System HL70005 Test Case Fixed
PID.10.5 Alternate Text
PID.10.6 Name of Alternate Coding System
PID.11 Patient Address
PID.11.1 Street Address
PID.11.1.1 Street or Mailing Address 4345 Standish Way Test Case Fixed
PID.11.1.2 Street Name
PID.11.1.3 Dwelling Number
PID.11.2 Other Designation
PID.11.3 City Stamford Test Case Fixed
PID.11.4 State or Province CT Test Case Fixed
PID.11.5 Zip or Postal Code 06903 Test Case Fixed
PID.11.6 Country USA Test Case Fixed
PID.11.7 Address Type L Test Case Fixed
PID.11 Patient Address
PID.11.1 Street Address
PID.11.1.1 Street or Mailing Address 325 Shorline Drive
PID.11.1.2 Street Name
PID.11.1.3 Dwelling Number
PID.11.2 Other Designation
PID.11.3 City Stamford
PID.11.4 State or Province CT Test Case Fixed
PID.11.5 Zip or Postal Code 06901
PID.11.6 Country
PID.11.7 Address Type BDL Test Case Fixed
PID.13 Phone Number - Home
PID.13.2 Telecommunication Use Code PRN Test Case Fixed
PID.13.3 Telecommunication Equipment Type PH Test Case Fixed
PID.13.4 Email Address
PID.13.6 Area/City Code 203 Test Case Fixed
PID.13.7 Local Number 5551212 Test Case Fixed
PID.22 Ethnic Group
PID.22.1 Identifier 2135-2 Test Case Fixed
PID.22.2 Text Hispanic or Latino Test Case Fixed
PID.22.3 Name of Coding System CDCREC Test Case Fixed
PID.22.5 Alternate Text
PID.22.6 Name of Alternate Coding System
PID.24 Multiple Birth Indicator
PID.25 Birth Order
PID.29 Patient Death Date and Time
PID.29.1 Time
PID.30 Patient Death Indicator

Location Data Element Data Categorization
PD1.11 Publicity Code
PD1.11.1 Identifier 02
PD1.11.2 Text Reminder/Recall - any method
PD1.11.3 Name of Coding System HL70215
PD1.11.5 Alternate Text
PD1.11.6 Name of Alternate Coding System
PD1.12 Protection Indicator
PD1.13 Protection Indicator Effective Date
PD1.16 Immunization Registry Status A
PD1.17 Immunization Registry Status Effective Date 20120701
PD1.18 Publicity Code Effective Date 20120701

Location Data Element Data Categorization
NK1.1 Set ID - NK1 1
NK1.2 Name
NK1.2.1 Family Name
NK1.2.1.1 Surname Gonzales
NK1.2.1.2 Own Surname Prefix
NK1.2.1.3 Own Surname
NK1.2.1.4 Surname Prefix From Partner/Spouse
NK1.2.1.5 Surname From Partner/Spouse
NK1.2.2 Given Name Joanna Test Case Fixed
NK1.2.3 Second and Further Given Names or Initials Thereof Merida Test Case Fixed
NK1.2.7 Name Type Code L Test Case Fixed
NK1.3 Relationship
NK1.3.1 Identifier GRP Test Case Fixed
NK1.3.2 Text Grandparent Test Case Fixed
NK1.3.3 Name of Coding System HL70063 Test Case Fixed
NK1.3.5 Alternate Text
NK1.3.6 Name of Alternate Coding System
NK1.4 Address
NK1.4.1 Street Address
NK1.4.1.1 Street or Mailing Address 4345 Standish Way Test Case Fixed
NK1.4.1.2 Street Name
NK1.4.1.3 Dwelling Number
NK1.4.2 Other Designation
NK1.4.3 City Stamford Test Case Fixed
NK1.4.4 State or Province CT Test Case Fixed
NK1.4.5 Zip or Postal Code 06901 Test Case Fixed
NK1.4.6 Country
NK1.4.7 Address Type L Test Case Fixed
NK1.5 Phone Number
NK1.5.2 Telecommunication Use Code PRN Test Case Fixed
NK1.5.3 Telecommunication Equipment Type PH Test Case Fixed
NK1.5.4 Email Address
NK1.5.6 Area/City Code 203 Test Case Fixed
NK1.5.7 Local Number 5551212 Test Case Fixed

ORC - 1
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Sirtis
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name Lisa
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Carter
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Jane
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier SH
ORC.17.2 Text Shoreline Hospital
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 2
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Molina
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name Sandra
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Smith
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Frank
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier SP
ORC.17.2 Text Shoreline Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 3
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 4
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 5
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 6
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L Test Case Fixed
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 7
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 8
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Molina
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name Sandra
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier SP
ORC.17.2 Text Shoreline Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 9
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 10
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 11
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 12
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 13
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 14
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 15
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Molina
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name Sandra
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier SP
ORC.17.2 Text Shoreline Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 16
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 9999
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Molina
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name Sandra
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Smith
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Frank
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier SP
ORC.17.2 Text Shoreline Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 17
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 18
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 19
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 20
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 21
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 22
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 23
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 24
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 25
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 26
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Molina
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name Sandra
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Ricci
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Gina
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier SP
ORC.17.2 Text Shoreline Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 27
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Molina Test Case Fixed
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name Sandra Test Case Fixed
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Smith Test Case Fixed
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Frank Test Case Fixed
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L Test Case Fixed
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier SP
ORC.17.2 Text Shoreline Pediatrics Test Case Fixed
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 28
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 29
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 30
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Smith
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name F
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 31
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Smith
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name F
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 32
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Smith
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name F
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 33
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Molina Test Case Fixed
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name Sandra Test Case Fixed
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Smith Test Case Fixed
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Frank Test Case Fixed
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L Test Case Fixed
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier SP
ORC.17.2 Text Shoreline Pediatrics Test Case Fixed
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

RXA - 1
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20091123
RXA.5 Administered Code
RXA.5.1 Identifier 08
RXA.5.2 Text hepatitis B vaccine, pediatric or pediatric/adolescent dosage
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text ENGERIX-B
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Sirtis
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name Lisa
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 6332FK33
RXA.16 Substance Expiration Date
RXA.16.1 Time 20101214
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier SKB
RXA.17.2 Text GlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 2
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100115
RXA.5 Administered Code
RXA.5.1 Identifier 45
RXA.5.2 Text hepatitis B vaccine, unspecified formulation
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text ENGERIX-B
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 01
RXA.9.2 Text Historical Immunization
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Molina
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name Sandra
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 6352FK1
RXA.16 Substance Expiration Date
RXA.16.1 Time 20101001
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier SKB
RXA.17.2 Text GlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 3
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20101030
RXA.5 Administered Code
RXA.5.1 Identifier 08
RXA.5.2 Text hepatitis B vaccine, pediatric or pediatric/adolescent dosage
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text ENGERIX-B
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 6352FK24
RXA.16 Substance Expiration Date
RXA.16.1 Time 20120831
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier SKB
RXA.17.2 Text GlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 4
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100122
RXA.5 Administered Code
RXA.5.1 Identifier 107
RXA.5.2 Text diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text DAPTACEL
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D409QS2341
RXA.16 Substance Expiration Date
RXA.16.1 Time 20111130
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi Pasteur Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 5
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100323
RXA.5 Administered Code
RXA.5.1 Identifier 106
RXA.5.2 Text diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text DAPTACEL
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D409QS2433
RXA.16 Substance Expiration Date
RXA.16.1 Time 20110904
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi Pasteur Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 6
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100522
RXA.5 Administered Code
RXA.5.1 Identifier 106
RXA.5.2 Text diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text DAPTACEL
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D409QS3255
RXA.16 Substance Expiration Date
RXA.16.1 Time 20101201
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi Pasteur Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 7
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20110221
RXA.5 Administered Code
RXA.5.1 Identifier 106
RXA.5.2 Text diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text DAPTACEL
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D409QS249
RXA.16 Substance Expiration Date
RXA.16.1 Time 20110301
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi Pasteur Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 8
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20140831
RXA.5 Administered Code
RXA.5.1 Identifier 106
RXA.5.2 Text diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text DAPTACEL
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 02
RXA.9.2 Text Historical information - from other provider
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Casera
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name Linda
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D643QS8243
RXA.16 Substance Expiration Date
RXA.16.1 Time 20140901
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi Pasteur Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 9
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100122
RXA.5 Administered Code
RXA.5.1 Identifier 49
RXA.5.2 Text Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text PedvaxHIB
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 7M54K9245
RXA.16 Substance Expiration Date
RXA.16.1 Time 20100324
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier MSD
RXA.17.2 Text Merck Sharp \T\ Dohme Corp
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 10
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100323
RXA.5 Administered Code
RXA.5.1 Identifier 49
RXA.5.2 Text Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text PedvaxHIB
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 7M55K3342
RXA.16 Substance Expiration Date
RXA.16.1 Time 20101030
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier MSD
RXA.17.2 Text Merck Sharp \T\ Dohme Corp
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 11
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100522
RXA.5 Administered Code
RXA.5.1 Identifier 49
RXA.5.2 Text Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text PedvaxHIB
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 7M75K4566
RXA.16 Substance Expiration Date
RXA.16.1 Time 20100523
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier MSD
RXA.17.2 Text Merck Sharp \T\ Dohme Corp
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 12
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20110221
RXA.5 Administered Code
RXA.5.1 Identifier 49
RXA.5.2 Text Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text PedvaxHIB
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 7M53K5534
RXA.16 Substance Expiration Date
RXA.16.1 Time 20110222
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier MSD
RXA.17.2 Text Merck Sharp \T\ Dohme Corp
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 13
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100122
RXA.5 Administered Code
RXA.5.1 Identifier 10
RXA.5.2 Text poliovirus vaccine, inactivated
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text IPOL
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D333PV2431
RXA.16 Substance Expiration Date
RXA.16.1 Time 20101004
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi Pasteur Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 14
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100323
RXA.5 Administered Code
RXA.5.1 Identifier 10
RXA.5.2 Text poliovirus vaccine, inactivated
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text IPOL
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D333PV4344
RXA.16 Substance Expiration Date
RXA.16.1 Time 20100323
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi Pasteur Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 15
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20110221
RXA.5 Administered Code
RXA.5.1 Identifier 10
RXA.5.2 Text poliovirus vaccine, inactivated
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text IPOL
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 02
RXA.9.2 Text Historical information - from other provider
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Casera
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name Linda
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D335PV9644
RXA.16 Substance Expiration Date
RXA.16.1 Time 20110222
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi Pasteur Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 16
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20150519
RXA.5 Administered Code
RXA.5.1 Identifier 10
RXA.5.2 Text poliovirus vaccine, inactivated
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text
RXA.5.6 Name of Alternate Coding System
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier
RXA.9.2 Text
RXA.9.3 Name of Coding System
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number
RXA.16 Substance Expiration Date
RXA.16.1 Time
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier
RXA.17.2 Text
RXA.17.3 Name of Coding System
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier 00
RXA.18.2 Text Parental decision
RXA.18.3 Name of Coding System NIP002
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status RE
RXA.21 Action Code - RXA A

RXA - 17
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100121
RXA.5 Administered Code
RXA.5.1 Identifier 133
RXA.5.2 Text pneumococcal conjugate vaccine, 13 valent
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text PREVNAR 13
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number P243V3281
RXA.16 Substance Expiration Date
RXA.16.1 Time 20100130
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PFR
RXA.17.2 Text Pfizer, Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 18
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100323
RXA.5 Administered Code
RXA.5.1 Identifier 133
RXA.5.2 Text pneumococcal conjugate vaccine, 13 valent
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text PREVNAR 13
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number P343V8321
RXA.16 Substance Expiration Date
RXA.16.1 Time 20100330
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PFR
RXA.17.2 Text Pfizer, Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 19
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100522
RXA.5 Administered Code
RXA.5.1 Identifier 133
RXA.5.2 Text pneumococcal conjugate vaccine, 13 valent
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text PREVNAR 13
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number P853V2164
RXA.16 Substance Expiration Date
RXA.16.1 Time 20100830
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PFR
RXA.17.2 Text Pfizer, Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 20
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20110221
RXA.5 Administered Code
RXA.5.1 Identifier 133
RXA.5.2 Text pneumococcal conjugate vaccine, 13 valent
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text PREVNAR 13
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number P853V58532
RXA.16 Substance Expiration Date
RXA.16.1 Time 20110418
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PFR
RXA.17.2 Text Pfizer, Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 21
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100122
RXA.5 Administered Code
RXA.5.1 Identifier 119
RXA.5.2 Text rotavirus, live, monovalent vaccine
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text ROTARIX
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 6359RV533
RXA.16 Substance Expiration Date
RXA.16.1 Time 20100215
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier SKB
RXA.17.2 Text GlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 22
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100323
RXA.5 Administered Code
RXA.5.1 Identifier 119
RXA.5.2 Text rotavirus, live, monovalent vaccine
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text ROTARIX
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 6359RV932
RXA.16 Substance Expiration Date
RXA.16.1 Time 20100510
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier SKB
RXA.17.2 Text GlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 23
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100925
RXA.5 Administered Code
RXA.5.1 Identifier 161
RXA.5.2 Text Influenza, injectable,quadrivalent, preservative free, pediatric
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text FLUZONE QUADRIVALENT
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D8043IN8734
RXA.16 Substance Expiration Date
RXA.16.1 Time 20110312
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 24
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20101027
RXA.5 Administered Code
RXA.5.1 Identifier 161
RXA.5.2 Text Influenza, injectable,quadrivalent, preservative free, pediatric
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text FLUZONE QUADRIVALENT
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D8043IN8734
RXA.16 Substance Expiration Date
RXA.16.1 Time 20110312
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 25
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20111002
RXA.5 Administered Code
RXA.5.1 Identifier 161
RXA.5.2 Text Influenza, injectable,quadrivalent, preservative free, pediatric
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text FLUZONE QUADRIVALENT
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D9334IN9333
RXA.16 Substance Expiration Date
RXA.16.1 Time 20120522
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 26
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20131015
RXA.5 Administered Code
RXA.5.1 Identifier 161
RXA.5.2 Text Influenza, injectable,quadrivalent, preservative free, pediatric
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text FLUZONE QUADRIVALENT
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 03
RXA.9.2 Text Historical information - from parents written record
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Ricci
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name Gina
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 8L4B3423
RXA.16 Substance Expiration Date
RXA.16.1 Time 20140701
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier MED
RXA.17.2 Text MedImmune, LLC
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 27
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20150715
RXA.5 Administered Code
RXA.5.1 Identifier 149 Test Case Fixed
RXA.5.2 Text influenza, live, intranasal, quadrivalent Test Case Fixed
RXA.5.3 Name of Coding System CVX Test Case Fixed
RXA.5.5 Alternate Text FluMist Quadrivalent Test Case Fixed
RXA.5.6 Name of Alternate Coding System NDC Test Case Fixed
RXA.6 Administered Amount 0.2 Test Case Fixed
RXA.7 Administered Units
RXA.7.1 Identifier mL Test Case Fixed
RXA.7.2 Text
RXA.7.3 Name of Coding System UCUM Test Case Fixed
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 00 Test Case Fixed
RXA.9.2 Text New immunization record Test Case Fixed
RXA.9.3 Name of Coding System NIP001 Test Case Fixed
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Molina Test Case Fixed
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name Sandra Test Case Fixed
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 8L4B3521 Test Case Fixed
RXA.16 Substance Expiration Date
RXA.16.1 Time 20150815 Test Case Fixed
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier MED Test Case Fixed
RXA.17.2 Text MedImmune,LLC Test Case Fixed
RXA.17.3 Name of Coding System MVX Test Case Fixed
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP Test Case Fixed
RXA.21 Action Code - RXA A

RXA - 28
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20121104
RXA.5 Administered Code
RXA.5.1 Identifier 149
RXA.5.2 Text influenza, live, intranasal, quadrivalent
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text FluMist Quadrivalent
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D9553IN2243
RXA.16 Substance Expiration Date
RXA.16.1 Time 20120430
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 29
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20111123
RXA.5 Administered Code
RXA.5.1 Identifier 83
RXA.5.2 Text hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text HAVRIX
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 6359RT33
RXA.16 Substance Expiration Date
RXA.16.1 Time 20120124
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier SKB
RXA.17.2 Text GlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 30
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20120523
RXA.5 Administered Code
RXA.5.1 Identifier 83
RXA.5.2 Text hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text HAVRIX
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 6359RT48
RXA.16 Substance Expiration Date
RXA.16.1 Time 20120911
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 31
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20101023
RXA.5 Administered Code
RXA.5.1 Identifier 94
RXA.5.2 Text measles, mumps, rubella, and varicella virus vaccine
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text ProQuad
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 01
RXA.9.2 Text historical
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 7W27V7491
RXA.16 Substance Expiration Date
RXA.16.1 Time 20101215
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier MSD
RXA.17.2 Text Merck Sharp \T\ Dohme Corp
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 32
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20121122
RXA.5 Administered Code
RXA.5.1 Identifier 94
RXA.5.2 Text measles, mumps, rubella, and varicella virus vaccine
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text ProQuad
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 7W87V3452
RXA.16 Substance Expiration Date
RXA.16.1 Time 20130413
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier MSD
RXA.17.2 Text Merck Sharp \T\ Dohme Corp
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 33
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20150715
RXA.5 Administered Code
RXA.5.1 Identifier 94 Test Case Fixed
RXA.5.2 Text measles, mumps, rubella, and varicella virus vaccine Test Case Fixed
RXA.5.3 Name of Coding System CVX Test Case Fixed
RXA.5.5 Alternate Text ProQuad Test Case Fixed
RXA.5.6 Name of Alternate Coding System NDC Test Case Fixed
RXA.6 Administered Amount 0.5 Test Case Fixed
RXA.7 Administered Units
RXA.7.1 Identifier mL Test Case Fixed
RXA.7.2 Text
RXA.7.3 Name of Coding System UCUM Test Case Fixed
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 00 Test Case Fixed
RXA.9.2 Text New immunization record Test Case Fixed
RXA.9.3 Name of Coding System NIP001 Test Case Fixed
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Molina Test Case Fixed
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name Sandra Test Case Fixed
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 7W87V3687 Test Case Fixed
RXA.16 Substance Expiration Date
RXA.16.1 Time 20150715 Test Case Fixed
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier MSD Test Case Fixed
RXA.17.2 Text Merck Sharp \T\ Dohme Corp Test Case Fixed
RXA.17.3 Name of Coding System MVX Test Case Fixed
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP Test Case Fixed
RXA.21 Action Code - RXA A

RXR - 1
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 2
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier RT
RXR.2.2 Text Right Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 3
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 4
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 5
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier RT
RXR.2.2 Text Right Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 6
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 7
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 8
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 9
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier RT
RXR.2.2 Text Right Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 10
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 11
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier RT
RXR.2.2 Text Right Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 12
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 13
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C38299
RXR.1.2 Text SC
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text Subcutaneous
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 14
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C38299
RXR.1.2 Text SC
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text Subcutaneous
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 15
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C38299
RXR.1.2 Text SC
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text Subcutaneous
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 16
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 17
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C38299
RXR.1.2 Text SC
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text Subcutaneous
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 18
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier RT
RXR.2.2 Text Right Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 19
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 20
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 21
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier RT
RXR.2.2 Text Right Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 22
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 23
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier RT
RXR.2.2 Text Right Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 24
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 25
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C38284
RXR.1.2 Text Nasal
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text Nasal
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier BN
RXR.2.2 Text Bilateral Nares
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 26
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C38284 Test Case Fixed
RXR.1.2 Text Nasal Test Case Fixed
RXR.1.3 Name of Coding System NCIT Test Case Fixed
RXR.1.5 Alternate Text Nasal Test Case Fixed
RXR.1.6 Name of Alternate Coding System HL70162 Test Case Fixed
RXR.2 Administration Site
RXR.2.1 Identifier BN
RXR.2.2 Text Bilateral Nares
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 27
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 28
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier RD
RXR.2.2 Text Right Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 29
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 30
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C38299
RXR.1.2 Text Subcutaneous
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text Subcutaneous
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 31
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C38299
RXR.1.2 Text Subcutaneous
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text Subcutaneous
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 32
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C38299 Test Case Fixed
RXR.1.2 Text Subcutaneous Test Case Fixed
RXR.1.3 Name of Coding System NCIT Test Case Fixed
RXR.1.5 Alternate Text Subcutaneous Test Case Fixed
RXR.1.6 Name of Alternate Coding System HL70162 Test Case Fixed
RXR.2 Administration Site
RXR.2.1 Identifier LD Test Case Fixed
RXR.2.2 Text Left Deltoid Test Case Fixed
RXR.2.3 Name of Coding System HL70163 Test Case Fixed
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

OBX - 1
Location Data Element Data Categorization
OBX.1 Set ID - OBX 21
OBX.2 Value Type CE
OBX.3 Observation Identifier
OBX.3.1 Identifier 31044-1
OBX.3.2 Text Reaction
OBX.3.3 Name of Coding System LN
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20100522
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 2
Location Data Element Data Categorization
OBX.1 Set ID - OBX 2
OBX.2 Value Type TS
OBX.3 Observation Identifier
OBX.3.1 Identifier 29768-9 Test Case Fixed
OBX.3.2 Text VIS Publication Date Test Case Fixed
OBX.3.3 Name of Coding System LN Test Case Fixed
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.5.1 Time 20140819
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 3
Location Data Element Data Categorization
OBX.1 Set ID - OBX 3
OBX.2 Value Type TS
OBX.3 Observation Identifier
OBX.3.1 Identifier 29769-7 Test Case Fixed
OBX.3.2 Text VIS Presentation Date Test Case Fixed
OBX.3.3 Name of Coding System LN Test Case Fixed
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.5.1 Time 20150715
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 4
Location Data Element Data Categorization
OBX.1 Set ID - OBX 1
OBX.2 Value Type CE
OBX.3 Observation Identifier
OBX.3.1 Identifier 64994-7 Test Case Fixed
OBX.3.2 Text vaccine fund pgm elig cat Test Case Fixed
OBX.3.3 Name of Coding System LN Test Case Fixed
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 5
Location Data Element Data Categorization
OBX.1 Set ID - OBX 2
OBX.2 Value Type TS
OBX.3 Observation Identifier
OBX.3.1 Identifier 29768-9 Test Case Fixed
OBX.3.2 Text VIS Publication Date Test Case Fixed
OBX.3.3 Name of Coding System LN Test Case Fixed
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.5.1 Time 20100521
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 6
Location Data Element Data Categorization
OBX.1 Set ID - OBX 3
OBX.2 Value Type TS
OBX.3 Observation Identifier
OBX.3.1 Identifier 29769-7 Test Case Fixed
OBX.3.2 Text VIS Presentation Date Test Case Fixed
OBX.3.3 Name of Coding System LN Test Case Fixed
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.5.1 Time 20150715
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 7
Location Data Element Data Categorization
OBX.1 Set ID - OBX 1
OBX.2 Value Type CE
OBX.3 Observation Identifier
OBX.3.1 Identifier 64994-7 Test Case Fixed
OBX.3.2 Text vaccine fund pgm elig cat Test Case Fixed
OBX.3.3 Name of Coding System LN Test Case Fixed
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

Test Data Specification

Patient Information
Element Data
Patient Name Juana Mariana Gonzales
Mother's Maiden Name Maria Acosta
ID Number 123456 987633
Date/Time of Birth 12/23/2009
Administrative Sex Female
Patient Address 4345 Standish Way Stamford CT 06903 USA
Patient Address 1 325 Shorline Drive Stamford CT 06901
Local Number (203)555-1212
Race Other Race
Ethnic Group Hispanic or Latino
Birth Order
Immunization Registry Information
Element Data
Immunization Registry Status A
Immunization Registry Status Effective Date 07/01/2012
Publicity Code Reminder/Recall - any method
Publicity Code Effective Date 07/01/2012
Protection Indicator
Protection Indicator Effective Date
Guardian or Responsible Party
Element Data
Name Joanna Merida Gonzales
Relationship Grandparent
Address 4345 Standish Way Stamford CT 06901
Phone Number (203)555-1212

Vaccine Administration Information[*]
Vaccine Administration Information - 1
Element Data
Administered Code hepatitis B vaccine, pediatric or pediatric/adolescent dosage
Date/Time Start of Administration 11/23/2009
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider Lisa Sirtis
Substance Lot Number 6332FK33
Substance Expiration Date 12/14/2010
Substance Manufacturer Name GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Thigh
Entering Organization Shoreline Hospital
Entered By Lisa Sirtis
Ordered By Jane Carter

Vaccine Administration Information - 2
Element Data
Administered Code hepatitis B vaccine, unspecified formulation
Date/Time Start of Administration 01/15/2010
Administered Amount 999
Administered Units
Administration Notes Historical Immunization
Administering Provider Sandra Molina
Substance Lot Number 6352FK1
Substance Expiration Date 10/01/2010
Substance Manufacturer Name GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Right Thigh
Entering Organization Shoreline Pediatrics
Entered By Sandra Molina
Ordered By Frank Smith

Vaccine Administration Information - 3
Element Data
Administered Code hepatitis B vaccine, pediatric or pediatric/adolescent dosage
Date/Time Start of Administration 10/30/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number 6352FK24
Substance Expiration Date 08/31/2012
Substance Manufacturer Name GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

Vaccine Administration Information - 4
Element Data
Administered Code diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Date/Time Start of Administration 01/22/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number D409QS2341
Substance Expiration Date 11/30/2011
Substance Manufacturer Name Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

Vaccine Administration Information - 5
Element Data
Administered Code diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Date/Time Start of Administration 03/23/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number D409QS2433
Substance Expiration Date 09/04/2011
Substance Manufacturer Name Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Right Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

Vaccine Administration Information - 6
Element Data
Administered Code diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Date/Time Start of Administration 05/22/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number D409QS3255
Substance Expiration Date 12/01/2010
Substance Manufacturer Name Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

Historical information - from public agency
Element Data
Reaction fever of >40.5C (105F) within 48 hours of dose

Vaccine Administration Information - 7
Element Data
Administered Code diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Date/Time Start of Administration 02/21/2011
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number D409QS249
Substance Expiration Date 03/01/2011
Substance Manufacturer Name Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

Vaccine Administration Information - 8
Element Data
Administered Code diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Date/Time Start of Administration 08/31/2014
Administered Amount 999
Administered Units
Administration Notes Historical information - from other provider
Administering Provider Linda Casera
Substance Lot Number D643QS8243
Substance Expiration Date 09/01/2014
Substance Manufacturer Name Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Deltoid
Entering Organization Shoreline Pediatrics
Entered By Sandra Molina
Ordered By J Rodriguez

Vaccine Administration Information - 9
Element Data
Administered Code Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Date/Time Start of Administration 01/22/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number 7M54K9245
Substance Expiration Date 03/24/2010
Substance Manufacturer Name Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Right Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

Vaccine Administration Information - 10
Element Data
Administered Code Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Date/Time Start of Administration 03/23/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number 7M55K3342
Substance Expiration Date 10/30/2010
Substance Manufacturer Name Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

Vaccine Administration Information - 11
Element Data
Administered Code Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Date/Time Start of Administration 05/22/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number 7M75K4566
Substance Expiration Date 05/23/2010
Substance Manufacturer Name Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Right Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

Vaccine Administration Information - 12
Element Data
Administered Code Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Date/Time Start of Administration 02/21/2011
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number 7M53K5534
Substance Expiration Date 02/22/2011
Substance Manufacturer Name Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

Vaccine Administration Information - 13
Element Data
Administered Code poliovirus vaccine, inactivated
Date/Time Start of Administration 01/22/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number D333PV2431
Substance Expiration Date 10/04/2010
Substance Manufacturer Name Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route SC
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

Vaccine Administration Information - 14
Element Data
Administered Code poliovirus vaccine, inactivated
Date/Time Start of Administration 03/23/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number D333PV4344
Substance Expiration Date 03/23/2010
Substance Manufacturer Name Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route SC
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

Vaccine Administration Information - 15
Element Data
Administered Code poliovirus vaccine, inactivated
Date/Time Start of Administration 02/21/2011
Administered Amount 999
Administered Units
Administration Notes Historical information - from other provider
Administering Provider Linda Casera
Substance Lot Number D335PV9644
Substance Expiration Date 02/22/2011
Substance Manufacturer Name Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route SC
Administration Site Left Deltoid
Entering Organization Shoreline Pediatrics
Entered By Sandra Molina
Ordered By J Rodriguez

Vaccine Administration Information - 16
Element Data
Administered Code poliovirus vaccine, inactivated
Date/Time Start of Administration 05/19/2015
Administered Amount 999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason Parental decision
Completion Status RE
Action Code Add
Route
Administration Site
Entering Organization Shoreline Pediatrics
Entered By Sandra Molina
Ordered By Frank Smith

Vaccine Administration Information - 17
Element Data
Administered Code pneumococcal conjugate vaccine, 13 valent
Date/Time Start of Administration 01/21/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number P243V3281
Substance Expiration Date 01/30/2010
Substance Manufacturer Name Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

Vaccine Administration Information - 18
Element Data
Administered Code pneumococcal conjugate vaccine, 13 valent
Date/Time Start of Administration 03/23/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number P343V8321
Substance Expiration Date 03/30/2010
Substance Manufacturer Name Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route SC
Administration Site Left Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

Vaccine Administration Information - 19
Element Data
Administered Code pneumococcal conjugate vaccine, 13 valent
Date/Time Start of Administration 05/22/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number P853V2164
Substance Expiration Date 08/30/2010
Substance Manufacturer Name Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Right Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

Vaccine Administration Information - 20
Element Data
Administered Code pneumococcal conjugate vaccine, 13 valent
Date/Time Start of Administration 02/21/2011
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number P853V58532
Substance Expiration Date 04/18/2011
Substance Manufacturer Name Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

Vaccine Administration Information - 21
Element Data
Administered Code rotavirus, live, monovalent vaccine
Date/Time Start of Administration 01/22/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number 6359RV533
Substance Expiration Date 02/15/2010
Substance Manufacturer Name GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

Vaccine Administration Information - 22
Element Data
Administered Code rotavirus, live, monovalent vaccine
Date/Time Start of Administration 03/23/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number 6359RV932
Substance Expiration Date 05/10/2010
Substance Manufacturer Name GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Right Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

Vaccine Administration Information - 23
Element Data
Administered Code Influenza, injectable,quadrivalent, preservative free, pediatric
Date/Time Start of Administration 09/25/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number D8043IN8734
Substance Expiration Date 03/12/2011
Substance Manufacturer Name Sanofi PasteurGlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

Vaccine Administration Information - 24
Element Data
Administered Code Influenza, injectable,quadrivalent, preservative free, pediatric
Date/Time Start of Administration 10/27/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number D8043IN8734
Substance Expiration Date 03/12/2011
Substance Manufacturer Name Sanofi PasteurGlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Right Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

Vaccine Administration Information - 25
Element Data
Administered Code Influenza, injectable,quadrivalent, preservative free, pediatric
Date/Time Start of Administration 10/02/2011
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number D9334IN9333
Substance Expiration Date 05/22/2012
Substance Manufacturer Name Sanofi PasteurGlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

Vaccine Administration Information - 26
Element Data
Administered Code Influenza, injectable,quadrivalent, preservative free, pediatric
Date/Time Start of Administration 10/15/2013
Administered Amount 999
Administered Units
Administration Notes Historical information - from parents written record
Administering Provider Gina Ricci
Substance Lot Number 8L4B3423
Substance Expiration Date 07/01/2014
Substance Manufacturer Name MedImmune, LLC
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route Nasal
Administration Site Bilateral Nares
Entering Organization Shoreline Pediatrics
Entered By Sandra Molina
Ordered By Gina Ricci

Vaccine Administration Information - 27
Element Data
Administered Code influenza, live, intranasal, quadrivalent
Date/Time Start of Administration 07/15/2015
Administered Amount 0.2
Administered Units
Administration Notes New immunization record
Administering Provider Sandra Molina
Substance Lot Number 8L4B3521
Substance Expiration Date 08/15/2015
Substance Manufacturer Name MedImmune,LLC
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route Nasal
Administration Site Bilateral Nares
Entering Organization Shoreline Pediatrics
Entered By Sandra Molina
Ordered By Frank Smith

Observations
Element Data
VIS Publication Date 08/19/2014
VIS Presentation Date 07/15/2015
vaccine fund pgm elig cat Not VFC elig

Vaccine Administration Information - 28
Element Data
Administered Code influenza, live, intranasal, quadrivalent
Date/Time Start of Administration 11/04/2012
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number D9553IN2243
Substance Expiration Date 04/30/2012
Substance Manufacturer Name Sanofi PasteurGlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

Vaccine Administration Information - 29
Element Data
Administered Code hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
Date/Time Start of Administration 11/23/2011
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number 6359RT33
Substance Expiration Date 01/24/2012
Substance Manufacturer Name GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Right Deltoid
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

Vaccine Administration Information - 30
Element Data
Administered Code hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
Date/Time Start of Administration 05/23/2012
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number 6359RT48
Substance Expiration Date 09/11/2012
Substance Manufacturer Name Sanofi PasteurGlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By F Smith

Vaccine Administration Information - 31
Element Data
Administered Code measles, mumps, rubella, and varicella virus vaccine
Date/Time Start of Administration 10/23/2010
Administered Amount 999
Administered Units
Administration Notes historical
Administering Provider J Martinez
Substance Lot Number 7W27V7491
Substance Expiration Date 12/15/2010
Substance Manufacturer Name Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route Subcutaneous
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By F Smith

Vaccine Administration Information - 32
Element Data
Administered Code measles, mumps, rubella, and varicella virus vaccine
Date/Time Start of Administration 11/22/2012
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number 7W87V3452
Substance Expiration Date 04/13/2013
Substance Manufacturer Name Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route Subcutaneous
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By F Smith

Vaccine Administration Information - 33
Element Data
Administered Code measles, mumps, rubella, and varicella virus vaccine
Date/Time Start of Administration 07/15/2015
Administered Amount 0.5
Administered Units
Administration Notes New immunization record
Administering Provider Sandra Molina
Substance Lot Number 7W87V3687
Substance Expiration Date 07/15/2015
Substance Manufacturer Name Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route Subcutaneous
Administration Site Left Deltoid
Entering Organization Shoreline Pediatrics
Entered By Sandra Molina
Ordered By Frank Smith

Observations
Element Data
VIS Publication Date 05/21/2010
VIS Presentation Date 07/15/2015
vaccine fund pgm elig cat Not VFC elig
Element Data
Patient Name Juana Mariana Gonzales
Mother's Maiden Name Maria Acosta
ID Number 123456 987633
Date/Time of Birth 12/23/2009
Administrative Sex Female
Patient Address 4345 Standish Way Stamford CT 06903 USA
Patient Address 1 325 Shorline Drive Stamford CT 06901
Local Number (203)555-1212
Race Other Race
Ethnic Group Hispanic or Latino
Birth Order
Element Data
Immunization Registry Status A
Immunization Registry Status Effective Date 07/01/2012
Publicity Code Reminder/Recall - any method
Publicity Code Effective Date 07/01/2012
Protection Indicator
Protection Indicator Effective Date
Element Data
Name Joanna Merida Gonzales
Relationship Grandparent
Address 4345 Standish Way Stamford CT 06901
Phone Number (203)555-1212
Vaccine Administration Information - 1
Element Data
Administered Code hepatitis B vaccine, pediatric or pediatric/adolescent dosage
Date/Time Start of Administration 11/23/2009
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider Lisa Sirtis
Substance Lot Number 6332FK33
Substance Expiration Date 12/14/2010
Substance Manufacturer Name GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Thigh
Entering Organization Shoreline Hospital
Entered By Lisa Sirtis
Ordered By Jane Carter

 Vaccine Administration Information - 2
Element Data
Administered Code hepatitis B vaccine, unspecified formulation
Date/Time Start of Administration 01/15/2010
Administered Amount 999
Administered Units
Administration Notes Historical Immunization
Administering Provider Sandra Molina
Substance Lot Number 6352FK1
Substance Expiration Date 10/01/2010
Substance Manufacturer Name GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Right Thigh
Entering Organization Shoreline Pediatrics
Entered By Sandra Molina
Ordered By Frank Smith

 Vaccine Administration Information - 3
Element Data
Administered Code hepatitis B vaccine, pediatric or pediatric/adolescent dosage
Date/Time Start of Administration 10/30/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number 6352FK24
Substance Expiration Date 08/31/2012
Substance Manufacturer Name GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

 Vaccine Administration Information - 4
Element Data
Administered Code diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Date/Time Start of Administration 01/22/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number D409QS2341
Substance Expiration Date 11/30/2011
Substance Manufacturer Name Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

 Vaccine Administration Information - 5
Element Data
Administered Code diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Date/Time Start of Administration 03/23/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number D409QS2433
Substance Expiration Date 09/04/2011
Substance Manufacturer Name Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Right Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

 Vaccine Administration Information - 6
Element Data
Administered Code diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Date/Time Start of Administration 05/22/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number D409QS3255
Substance Expiration Date 12/01/2010
Substance Manufacturer Name Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

Historical information - from public agency
Element Data
Reaction fever of >40.5C (105F) within 48 hours of dose

 Vaccine Administration Information - 7
Element Data
Administered Code diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Date/Time Start of Administration 02/21/2011
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number D409QS249
Substance Expiration Date 03/01/2011
Substance Manufacturer Name Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

 Vaccine Administration Information - 8
Element Data
Administered Code diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Date/Time Start of Administration 08/31/2014
Administered Amount 999
Administered Units
Administration Notes Historical information - from other provider
Administering Provider Linda Casera
Substance Lot Number D643QS8243
Substance Expiration Date 09/01/2014
Substance Manufacturer Name Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Deltoid
Entering Organization Shoreline Pediatrics
Entered By Sandra Molina
Ordered By J Rodriguez

 Vaccine Administration Information - 9
Element Data
Administered Code Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Date/Time Start of Administration 01/22/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number 7M54K9245
Substance Expiration Date 03/24/2010
Substance Manufacturer Name Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Right Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

 Vaccine Administration Information - 10
Element Data
Administered Code Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Date/Time Start of Administration 03/23/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number 7M55K3342
Substance Expiration Date 10/30/2010
Substance Manufacturer Name Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

 Vaccine Administration Information - 11
Element Data
Administered Code Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Date/Time Start of Administration 05/22/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number 7M75K4566
Substance Expiration Date 05/23/2010
Substance Manufacturer Name Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Right Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

 Vaccine Administration Information - 12
Element Data
Administered Code Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Date/Time Start of Administration 02/21/2011
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number 7M53K5534
Substance Expiration Date 02/22/2011
Substance Manufacturer Name Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

 Vaccine Administration Information - 13
Element Data
Administered Code poliovirus vaccine, inactivated
Date/Time Start of Administration 01/22/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number D333PV2431
Substance Expiration Date 10/04/2010
Substance Manufacturer Name Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route SC
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

 Vaccine Administration Information - 14
Element Data
Administered Code poliovirus vaccine, inactivated
Date/Time Start of Administration 03/23/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number D333PV4344
Substance Expiration Date 03/23/2010
Substance Manufacturer Name Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route SC
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

 Vaccine Administration Information - 15
Element Data
Administered Code poliovirus vaccine, inactivated
Date/Time Start of Administration 02/21/2011
Administered Amount 999
Administered Units
Administration Notes Historical information - from other provider
Administering Provider Linda Casera
Substance Lot Number D335PV9644
Substance Expiration Date 02/22/2011
Substance Manufacturer Name Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route SC
Administration Site Left Deltoid
Entering Organization Shoreline Pediatrics
Entered By Sandra Molina
Ordered By J Rodriguez

 Vaccine Administration Information - 16
Element Data
Administered Code poliovirus vaccine, inactivated
Date/Time Start of Administration 05/19/2015
Administered Amount 999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason Parental decision
Completion Status RE
Action Code Add
Route
Administration Site
Entering Organization Shoreline Pediatrics
Entered By Sandra Molina
Ordered By Frank Smith

 Vaccine Administration Information - 17
Element Data
Administered Code pneumococcal conjugate vaccine, 13 valent
Date/Time Start of Administration 01/21/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number P243V3281
Substance Expiration Date 01/30/2010
Substance Manufacturer Name Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

 Vaccine Administration Information - 18
Element Data
Administered Code pneumococcal conjugate vaccine, 13 valent
Date/Time Start of Administration 03/23/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number P343V8321
Substance Expiration Date 03/30/2010
Substance Manufacturer Name Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route SC
Administration Site Left Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

 Vaccine Administration Information - 19
Element Data
Administered Code pneumococcal conjugate vaccine, 13 valent
Date/Time Start of Administration 05/22/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number P853V2164
Substance Expiration Date 08/30/2010
Substance Manufacturer Name Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Right Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

 Vaccine Administration Information - 20
Element Data
Administered Code pneumococcal conjugate vaccine, 13 valent
Date/Time Start of Administration 02/21/2011
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number P853V58532
Substance Expiration Date 04/18/2011
Substance Manufacturer Name Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

 Vaccine Administration Information - 21
Element Data
Administered Code rotavirus, live, monovalent vaccine
Date/Time Start of Administration 01/22/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number 6359RV533
Substance Expiration Date 02/15/2010
Substance Manufacturer Name GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

 Vaccine Administration Information - 22
Element Data
Administered Code rotavirus, live, monovalent vaccine
Date/Time Start of Administration 03/23/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number 6359RV932
Substance Expiration Date 05/10/2010
Substance Manufacturer Name GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Right Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

 Vaccine Administration Information - 23
Element Data
Administered Code Influenza, injectable,quadrivalent, preservative free, pediatric
Date/Time Start of Administration 09/25/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number D8043IN8734
Substance Expiration Date 03/12/2011
Substance Manufacturer Name Sanofi PasteurGlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

 Vaccine Administration Information - 24
Element Data
Administered Code Influenza, injectable,quadrivalent, preservative free, pediatric
Date/Time Start of Administration 10/27/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number D8043IN8734
Substance Expiration Date 03/12/2011
Substance Manufacturer Name Sanofi PasteurGlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Right Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

 Vaccine Administration Information - 25
Element Data
Administered Code Influenza, injectable,quadrivalent, preservative free, pediatric
Date/Time Start of Administration 10/02/2011
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number D9334IN9333
Substance Expiration Date 05/22/2012
Substance Manufacturer Name Sanofi PasteurGlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

 Vaccine Administration Information - 26
Element Data
Administered Code Influenza, injectable,quadrivalent, preservative free, pediatric
Date/Time Start of Administration 10/15/2013
Administered Amount 999
Administered Units
Administration Notes Historical information - from parents written record
Administering Provider Gina Ricci
Substance Lot Number 8L4B3423
Substance Expiration Date 07/01/2014
Substance Manufacturer Name MedImmune, LLC
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route Nasal
Administration Site Bilateral Nares
Entering Organization Shoreline Pediatrics
Entered By Sandra Molina
Ordered By Gina Ricci

 Vaccine Administration Information - 27
Element Data
Administered Code influenza, live, intranasal, quadrivalent
Date/Time Start of Administration 07/15/2015
Administered Amount 0.2
Administered Units
Administration Notes New immunization record
Administering Provider Sandra Molina
Substance Lot Number 8L4B3521
Substance Expiration Date 08/15/2015
Substance Manufacturer Name MedImmune,LLC
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route Nasal
Administration Site Bilateral Nares
Entering Organization Shoreline Pediatrics
Entered By Sandra Molina
Ordered By Frank Smith

Observations
Element Data
VIS Publication Date 08/19/2014
VIS Presentation Date 07/15/2015
vaccine fund pgm elig cat Not VFC elig

 Vaccine Administration Information - 28
Element Data
Administered Code influenza, live, intranasal, quadrivalent
Date/Time Start of Administration 11/04/2012
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number D9553IN2243
Substance Expiration Date 04/30/2012
Substance Manufacturer Name Sanofi PasteurGlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

 Vaccine Administration Information - 29
Element Data
Administered Code hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
Date/Time Start of Administration 11/23/2011
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number 6359RT33
Substance Expiration Date 01/24/2012
Substance Manufacturer Name GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Right Deltoid
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

 Vaccine Administration Information - 30
Element Data
Administered Code hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
Date/Time Start of Administration 05/23/2012
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number 6359RT48
Substance Expiration Date 09/11/2012
Substance Manufacturer Name Sanofi PasteurGlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By F Smith

 Vaccine Administration Information - 31
Element Data
Administered Code measles, mumps, rubella, and varicella virus vaccine
Date/Time Start of Administration 10/23/2010
Administered Amount 999
Administered Units
Administration Notes historical
Administering Provider J Martinez
Substance Lot Number 7W27V7491
Substance Expiration Date 12/15/2010
Substance Manufacturer Name Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route Subcutaneous
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By F Smith

 Vaccine Administration Information - 32
Element Data
Administered Code measles, mumps, rubella, and varicella virus vaccine
Date/Time Start of Administration 11/22/2012
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number 7W87V3452
Substance Expiration Date 04/13/2013
Substance Manufacturer Name Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route Subcutaneous
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By F Smith

 Vaccine Administration Information - 33
Element Data
Administered Code measles, mumps, rubella, and varicella virus vaccine
Date/Time Start of Administration 07/15/2015
Administered Amount 0.5
Administered Units
Administration Notes New immunization record
Administering Provider Sandra Molina
Substance Lot Number 7W87V3687
Substance Expiration Date 07/15/2015
Substance Manufacturer Name Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route Subcutaneous
Administration Site Left Deltoid
Entering Organization Shoreline Pediatrics
Entered By Sandra Molina
Ordered By Frank Smith

Observations
Element Data
VIS Publication Date 05/21/2010
VIS Presentation Date 07/15/2015
vaccine fund pgm elig cat Not VFC elig

4.1.2. Record an adverse reaction

Test Step Type: SUT_MANUAL
The Provider records in the EMR an adverse reaction of persistent, inconsolable crying lasting > 3 hours within 48 hours of dose.

Test Story

Description

Following the vaccine administration, the patient's mother reports that the patient that evening had persistent, inconsolable crying lasting > 3 hours.

Comments

No Comments

PreCondition

The vaccinations for the visit have been administered.

PostCondition

The adverse reaction to the MMRV  of persistent, inconsolable crying lasting > 3 hours within 48 hours of dose is recorded in the EMR.

Test Objectives

Identify Adverse Event: The EHR or other clinical software system enables capture of structured data regarding adverse events.

Evaluation Criteria

Verify that vendor can record the adverse reaction of  persistent, inconsolable crying lasting > 3 hours within 48 hours of dose correctly and without omission

Notes to Testers

No Note

4.1.3. Transmit the updated vaccination report with adverse reaction to the registry

Test Step Type: SUT_INITIATOR
The EMR generates a Z22 Send Unsolicited Immunization Update Using a VXU correctly and without omission according to supplied test data.

Test Story

Description

The adverse reaction to the MMRV of persistent, inconsolable crying lasting > 3 hours within 48 hours of dose is reported to the Immunization Registry using a Z22/VXU message.

Comments

No Comments

PreCondition

An adverse reaction to the MMRV of persistent, inconsolable crying lasting > 3 hours within 48 hours of dose is recorded in the EMR.

PostCondition

The adverse reaction has been transmitted to the IIS.

Test Objectives

Transmit Standard Patient Immunization History Report: The EHR or other clinical software system directly or indirectly through an intermediary creates and transmits a report of a patient's immunization history to public health immunization registries.

Evaluation Criteria

The VXU/Z22 message passes validation using the NIST Immunization VXU Validation Tool (Z22) (context-free). The content of the message correctly reflects the test data (context-based) in accordance with the Test Data Specification and the Message Content.

Notes to Testers

No Note

Message Contents

MSH
Location Data Element Data Categorization
MSH.1 Field Separator |
MSH.2 Encoding Characters ^~\&
MSH.3 Sending Application
MSH.3.1 Namespace ID Test EHR Application
MSH.3.2 Universal ID
MSH.3.3 Universal ID Type
MSH.4 Sending Facility
MSH.4.1 Namespace ID X68
MSH.4.2 Universal ID
MSH.4.3 Universal ID Type
MSH.5 Receiving Application
MSH.5.1 Namespace ID
MSH.5.2 Universal ID
MSH.5.3 Universal ID Type
MSH.6 Receiving Facility
MSH.6.1 Namespace ID NIST Test Iz Reg
MSH.6.2 Universal ID
MSH.6.3 Universal ID Type
MSH.7 Date/Time Of Message
MSH.7.1 Time 20120701082240-0500
MSH.9 Message Type
MSH.9.1 Message Code VXU
MSH.9.2 Trigger Event V04
MSH.9.3 Message Structure VXU_V04
MSH.10 Message Control ID NIST-IZ-001.00
MSH.11 Processing ID
MSH.11.1 Processing ID P
MSH.12 Version ID
MSH.12.1 Version ID 2.5.1
MSH.15 Accept Acknowledgment Type ER
MSH.16 Application Acknowledgment Type AL
MSH.21 Message Profile Identifier
MSH.21.1 Entity Identifier Z22
MSH.21.2 Namespace ID CDCPHINVS
MSH.21.3 Universal ID
MSH.21.4 Universal ID Type
MSH.22 Sending Responsible Organization
MSH.22.1 Organization Name
MSH.22.6 Assigning Authority
MSH.22.6.1 Namespace ID
MSH.22.6.2 Universal ID
MSH.22.6.3 Universal ID Type
MSH.22.7 Identifier Type Code
MSH.22.10 Organization Identifier
MSH.23 Receiving Responsible Organization
MSH.23.1 Organization Name
MSH.23.6 Assigning Authority
MSH.23.6.1 Namespace ID
MSH.23.6.2 Universal ID
MSH.23.6.3 Universal ID Type
MSH.23.7 Identifier Type Code
MSH.23.10 Organization Identifier

PID
Location Data Element Data Categorization
PID.1 Set ID - PID 1
PID.3 Patient Identifier List
PID.3.1 ID Number 123456
PID.3.3 Check Digit Scheme
PID.3.4 Assigning Authority
PID.3.4.1 Namespace ID MYEHR
PID.3.4.2 Universal ID
PID.3.4.3 Universal ID Type
PID.3.5 Identifier Type Code MR
PID.3 Patient Identifier List
PID.3.1 ID Number 987633
PID.3.3 Check Digit Scheme
PID.3.4 Assigning Authority
PID.3.4.1 Namespace ID MYIIS
PID.3.4.2 Universal ID
PID.3.4.3 Universal ID Type
PID.3.5 Identifier Type Code SR
PID.5 Patient Name
PID.5.1 Family Name
PID.5.1.1 Surname Gonzales Test Case Fixed
PID.5.1.2 Own Surname Prefix
PID.5.1.3 Own Surname
PID.5.1.4 Surname Prefix From Partner/Spouse
PID.5.1.5 Surname From Partner/Spouse
PID.5.2 Given Name Juana Test Case Fixed
PID.5.3 Second and Further Given Names or Initials Thereof Mariana Test Case Fixed
PID.5.7 Name Type Code L Test Case Fixed
PID.6 Mother's Maiden Name
PID.6.1 Family Name
PID.6.1.1 Surname Acosta Test Case Fixed
PID.6.1.2 Own Surname Prefix
PID.6.1.3 Own Surname
PID.6.1.4 Surname Prefix From Partner/Spouse
PID.6.1.5 Surname From Partner/Spouse
PID.6.7 Name Type Code M Test Case Fixed
PID.7 Date/Time of Birth
PID.7.1 Time 200912231105 Test Case Fixed
PID.8 Administrative Sex F Test Case Fixed
PID.10 Race
PID.10.1 Identifier 2131-1 Test Case Fixed
PID.10.2 Text Other Race Test Case Fixed
PID.10.3 Name of Coding System HL70005 Test Case Fixed
PID.10.5 Alternate Text
PID.10.6 Name of Alternate Coding System
PID.11 Patient Address
PID.11.1 Street Address
PID.11.1.1 Street or Mailing Address 4345 Standish Way Test Case Fixed
PID.11.1.2 Street Name
PID.11.1.3 Dwelling Number
PID.11.2 Other Designation
PID.11.3 City Stamford Test Case Fixed
PID.11.4 State or Province CT Test Case Fixed
PID.11.5 Zip or Postal Code 06903 Test Case Fixed
PID.11.6 Country USA Test Case Fixed
PID.11.7 Address Type L Test Case Fixed
PID.11 Patient Address
PID.11.1 Street Address
PID.11.1.1 Street or Mailing Address 325 Shorline Drive
PID.11.1.2 Street Name
PID.11.1.3 Dwelling Number
PID.11.2 Other Designation
PID.11.3 City Stamford
PID.11.4 State or Province CT Test Case Fixed
PID.11.5 Zip or Postal Code 06901
PID.11.6 Country
PID.11.7 Address Type BDL Test Case Fixed
PID.13 Phone Number - Home
PID.13.2 Telecommunication Use Code PRN Test Case Fixed
PID.13.3 Telecommunication Equipment Type PH Test Case Fixed
PID.13.4 Email Address
PID.13.6 Area/City Code 203 Test Case Fixed
PID.13.7 Local Number 5551212 Test Case Fixed
PID.22 Ethnic Group
PID.22.1 Identifier 2135-2 Test Case Fixed
PID.22.2 Text Hispanic or Latino Test Case Fixed
PID.22.3 Name of Coding System CDCREC Test Case Fixed
PID.22.5 Alternate Text
PID.22.6 Name of Alternate Coding System
PID.24 Multiple Birth Indicator
PID.25 Birth Order
PID.29 Patient Death Date and Time
PID.29.1 Time
PID.30 Patient Death Indicator

PD1
Location Data Element Data Categorization
PD1.11 Publicity Code
PD1.11.1 Identifier 02
PD1.11.2 Text Reminder/Recall - any method
PD1.11.3 Name of Coding System HL70215
PD1.11.5 Alternate Text
PD1.11.6 Name of Alternate Coding System
PD1.12 Protection Indicator
PD1.13 Protection Indicator Effective Date
PD1.16 Immunization Registry Status A
PD1.17 Immunization Registry Status Effective Date 20120701
PD1.18 Publicity Code Effective Date 20120701

NK1
Location Data Element Data Categorization
NK1.1 Set ID - NK1 1
NK1.2 Name
NK1.2.1 Family Name
NK1.2.1.1 Surname Gonzales
NK1.2.1.2 Own Surname Prefix
NK1.2.1.3 Own Surname
NK1.2.1.4 Surname Prefix From Partner/Spouse
NK1.2.1.5 Surname From Partner/Spouse
NK1.2.2 Given Name Joanna Test Case Fixed
NK1.2.3 Second and Further Given Names or Initials Thereof Merida Test Case Fixed
NK1.2.7 Name Type Code L Test Case Fixed
NK1.3 Relationship
NK1.3.1 Identifier GRP Test Case Fixed
NK1.3.2 Text Grandparent Test Case Fixed
NK1.3.3 Name of Coding System HL70063 Test Case Fixed
NK1.3.5 Alternate Text
NK1.3.6 Name of Alternate Coding System
NK1.4 Address
NK1.4.1 Street Address
NK1.4.1.1 Street or Mailing Address 4345 Standish Way Test Case Fixed
NK1.4.1.2 Street Name
NK1.4.1.3 Dwelling Number
NK1.4.2 Other Designation
NK1.4.3 City Stamford Test Case Fixed
NK1.4.4 State or Province CT Test Case Fixed
NK1.4.5 Zip or Postal Code 06901 Test Case Fixed
NK1.4.6 Country
NK1.4.7 Address Type L Test Case Fixed
NK1.5 Phone Number
NK1.5.2 Telecommunication Use Code PRN Test Case Fixed
NK1.5.3 Telecommunication Equipment Type PH Test Case Fixed
NK1.5.4 Email Address
NK1.5.6 Area/City Code 203 Test Case Fixed
NK1.5.7 Local Number 5551212 Test Case Fixed

ORC[*]
ORC - 1
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Sirtis
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name Lisa
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Carter
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Jane
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier SH
ORC.17.2 Text Shoreline Hospital
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 2
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Molina
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name Sandra
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Smith
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Frank
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier SP
ORC.17.2 Text Shoreline Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 3
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 4
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 5
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 6
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L Test Case Fixed
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 7
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 8
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Molina
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name Sandra
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier SP
ORC.17.2 Text Shoreline Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 9
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 10
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 11
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 12
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 13
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 14
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 15
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Molina
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name Sandra
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier SP
ORC.17.2 Text Shoreline Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 16
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 9999
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Molina
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name Sandra
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Smith
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Frank
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier SP
ORC.17.2 Text Shoreline Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 17
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 18
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 19
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 20
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 21
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 22
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 23
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 24
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 25
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 26
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Molina
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name Sandra
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Ricci
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Gina
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier SP
ORC.17.2 Text Shoreline Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 27
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Molina
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name Sandra
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Smith
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Frank
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier SP
ORC.17.2 Text Shoreline Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 28
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 29
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 30
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Smith
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name F
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 31
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Smith
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name F
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 32
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Smith
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name F
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 33
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Molina Test Case Fixed
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name Sandra Test Case Fixed
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Smith Test Case Fixed
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Frank Test Case Fixed
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L Test Case Fixed
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier SP
ORC.17.2 Text Shoreline Pediatrics Test Case Fixed
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

RXA[*]
RXA - 1
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20091123
RXA.5 Administered Code
RXA.5.1 Identifier 08
RXA.5.2 Text hepatitis B vaccine, pediatric or pediatric/adolescent dosage
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text ENGERIX-B
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Sirtis
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name Lisa
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 6332FK33
RXA.16 Substance Expiration Date
RXA.16.1 Time 20101214
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier SKB
RXA.17.2 Text GlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 2
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100115
RXA.5 Administered Code
RXA.5.1 Identifier 45
RXA.5.2 Text hepatitis B vaccine, unspecified formulation
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text ENGERIX-B
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 01
RXA.9.2 Text Historical Immunization
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Molina
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name Sandra
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 6352FK1
RXA.16 Substance Expiration Date
RXA.16.1 Time 20101001
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier SKB
RXA.17.2 Text GlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 3
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20101030
RXA.5 Administered Code
RXA.5.1 Identifier 08
RXA.5.2 Text hepatitis B vaccine, pediatric or pediatric/adolescent dosage
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text ENGERIX-B
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 6352FK24
RXA.16 Substance Expiration Date
RXA.16.1 Time 20120831
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier SKB
RXA.17.2 Text GlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 4
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100122
RXA.5 Administered Code
RXA.5.1 Identifier 107
RXA.5.2 Text diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text DAPTACEL
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D409QS2341
RXA.16 Substance Expiration Date
RXA.16.1 Time 20111130
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi Pasteur Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 5
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100323
RXA.5 Administered Code
RXA.5.1 Identifier 106
RXA.5.2 Text diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text DAPTACEL
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D409QS2433
RXA.16 Substance Expiration Date
RXA.16.1 Time 20110904
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi Pasteur Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 6
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100522
RXA.5 Administered Code
RXA.5.1 Identifier 106
RXA.5.2 Text diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text DAPTACEL
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D409QS3255
RXA.16 Substance Expiration Date
RXA.16.1 Time 20101201
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi Pasteur Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 7
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20110221
RXA.5 Administered Code
RXA.5.1 Identifier 106
RXA.5.2 Text diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text DAPTACEL
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D409QS249
RXA.16 Substance Expiration Date
RXA.16.1 Time 20110301
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi Pasteur Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 8
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20140831
RXA.5 Administered Code
RXA.5.1 Identifier 106
RXA.5.2 Text diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text DAPTACEL
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 02
RXA.9.2 Text Historical information - from other provider
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Casera
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name Linda
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D643QS8243
RXA.16 Substance Expiration Date
RXA.16.1 Time 20140901
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi Pasteur Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 9
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100122
RXA.5 Administered Code
RXA.5.1 Identifier 49
RXA.5.2 Text Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text PedvaxHIB
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 7M54K9245
RXA.16 Substance Expiration Date
RXA.16.1 Time 20100324
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier MSD
RXA.17.2 Text Merck Sharp \T\ Dohme Corp
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 10
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100323
RXA.5 Administered Code
RXA.5.1 Identifier 49
RXA.5.2 Text Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text PedvaxHIB
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 7M55K3342
RXA.16 Substance Expiration Date
RXA.16.1 Time 20101030
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier MSD
RXA.17.2 Text Merck Sharp \T\ Dohme Corp
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 11
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100522
RXA.5 Administered Code
RXA.5.1 Identifier 49
RXA.5.2 Text Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text PedvaxHIB
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 7M75K4566
RXA.16 Substance Expiration Date
RXA.16.1 Time 20100523
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier MSD
RXA.17.2 Text Merck Sharp \T\ Dohme Corp
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 12
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20110221
RXA.5 Administered Code
RXA.5.1 Identifier 49
RXA.5.2 Text Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text PedvaxHIB
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 7M53K5534
RXA.16 Substance Expiration Date
RXA.16.1 Time 20110222
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier MSD
RXA.17.2 Text Merck Sharp \T\ Dohme Corp
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 13
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100122
RXA.5 Administered Code
RXA.5.1 Identifier 10
RXA.5.2 Text poliovirus vaccine, inactivated
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text IPOL
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D333PV2431
RXA.16 Substance Expiration Date
RXA.16.1 Time 20101004
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi Pasteur Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 14
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100323
RXA.5 Administered Code
RXA.5.1 Identifier 10
RXA.5.2 Text poliovirus vaccine, inactivated
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text IPOL
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D333PV4344
RXA.16 Substance Expiration Date
RXA.16.1 Time 20100323
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi Pasteur Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 15
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20110221
RXA.5 Administered Code
RXA.5.1 Identifier 10
RXA.5.2 Text poliovirus vaccine, inactivated
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text IPOL
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 02
RXA.9.2 Text Historical information - from other provider
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Casera
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name Linda
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D335PV9644
RXA.16 Substance Expiration Date
RXA.16.1 Time 20110222
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi Pasteur Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 16
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20150519
RXA.5 Administered Code
RXA.5.1 Identifier 10
RXA.5.2 Text poliovirus vaccine, inactivated
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text
RXA.5.6 Name of Alternate Coding System
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier
RXA.9.2 Text
RXA.9.3 Name of Coding System
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number
RXA.16 Substance Expiration Date
RXA.16.1 Time
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier
RXA.17.2 Text
RXA.17.3 Name of Coding System
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier 00
RXA.18.2 Text Parental decision
RXA.18.3 Name of Coding System NIP002
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status RE
RXA.21 Action Code - RXA A

RXA - 17
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100121
RXA.5 Administered Code
RXA.5.1 Identifier 133
RXA.5.2 Text pneumococcal conjugate vaccine, 13 valent
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text PREVNAR 13
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number P243V3281
RXA.16 Substance Expiration Date
RXA.16.1 Time 20100130
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PFR
RXA.17.2 Text Pfizer, Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 18
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100323
RXA.5 Administered Code
RXA.5.1 Identifier 133
RXA.5.2 Text pneumococcal conjugate vaccine, 13 valent
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text PREVNAR 13
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number P343V8321
RXA.16 Substance Expiration Date
RXA.16.1 Time 20100330
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PFR
RXA.17.2 Text Pfizer, Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 19
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100522
RXA.5 Administered Code
RXA.5.1 Identifier 133
RXA.5.2 Text pneumococcal conjugate vaccine, 13 valent
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text PREVNAR 13
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number P853V2164
RXA.16 Substance Expiration Date
RXA.16.1 Time 20100830
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PFR
RXA.17.2 Text Pfizer, Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 20
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20110221
RXA.5 Administered Code
RXA.5.1 Identifier 133
RXA.5.2 Text pneumococcal conjugate vaccine, 13 valent
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text PREVNAR 13
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number P853V58532
RXA.16 Substance Expiration Date
RXA.16.1 Time 20110418
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PFR
RXA.17.2 Text Pfizer, Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 21
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100122
RXA.5 Administered Code
RXA.5.1 Identifier 119
RXA.5.2 Text rotavirus, live, monovalent vaccine
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text ROTARIX
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 6359RV533
RXA.16 Substance Expiration Date
RXA.16.1 Time 20100215
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier SKB
RXA.17.2 Text GlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 22
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100323
RXA.5 Administered Code
RXA.5.1 Identifier 119
RXA.5.2 Text rotavirus, live, monovalent vaccine
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text ROTARIX
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 6359RV932
RXA.16 Substance Expiration Date
RXA.16.1 Time 20100510
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier SKB
RXA.17.2 Text GlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 23
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100925
RXA.5 Administered Code
RXA.5.1 Identifier 161
RXA.5.2 Text Influenza, injectable,quadrivalent, preservative free, pediatric
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text FLUZONE QUADRIVALENT
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D8043IN8734
RXA.16 Substance Expiration Date
RXA.16.1 Time 20110312
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 24
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20101027
RXA.5 Administered Code
RXA.5.1 Identifier 161
RXA.5.2 Text Influenza, injectable,quadrivalent, preservative free, pediatric
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text FLUZONE QUADRIVALENT
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D8043IN8734
RXA.16 Substance Expiration Date
RXA.16.1 Time 20110312
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 25
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20111002
RXA.5 Administered Code
RXA.5.1 Identifier 161
RXA.5.2 Text Influenza, injectable,quadrivalent, preservative free, pediatric
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text FLUZONE QUADRIVALENT
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D9334IN9333
RXA.16 Substance Expiration Date
RXA.16.1 Time 20120522
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 26
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20131015
RXA.5 Administered Code
RXA.5.1 Identifier 161
RXA.5.2 Text Influenza, injectable,quadrivalent, preservative free, pediatric
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text FLUZONE QUADRIVALENT
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 03
RXA.9.2 Text Historical information - from parents written record
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Ricci
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name Gina
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 8L4B3423
RXA.16 Substance Expiration Date
RXA.16.1 Time 20140701
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier MED
RXA.17.2 Text MedImmune, LLC
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 27
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20150715
RXA.5 Administered Code
RXA.5.1 Identifier 149
RXA.5.2 Text influenza, live, intranasal, quadrivalent
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text FluMist Quadrivalent
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 0.2
RXA.7 Administered Units
RXA.7.1 Identifier mL
RXA.7.2 Text
RXA.7.3 Name of Coding System UCUM
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 00
RXA.9.2 Text New immunization record
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Molina
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name Sandra
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 8L4B3521
RXA.16 Substance Expiration Date
RXA.16.1 Time 20150815
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier MED
RXA.17.2 Text MedImmune,LLC
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 28
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20121104
RXA.5 Administered Code
RXA.5.1 Identifier 149
RXA.5.2 Text influenza, live, intranasal, quadrivalent
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text FluMist Quadrivalent
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D9553IN2243
RXA.16 Substance Expiration Date
RXA.16.1 Time 20120430
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 29
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20111123
RXA.5 Administered Code
RXA.5.1 Identifier 83
RXA.5.2 Text hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text HAVRIX
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 6359RT33
RXA.16 Substance Expiration Date
RXA.16.1 Time 20120124
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier SKB
RXA.17.2 Text GlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 30
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20120523
RXA.5 Administered Code
RXA.5.1 Identifier 83
RXA.5.2 Text hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text HAVRIX
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 6359RT48
RXA.16 Substance Expiration Date
RXA.16.1 Time 20120911
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 31
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20101023
RXA.5 Administered Code
RXA.5.1 Identifier 94
RXA.5.2 Text measles, mumps, rubella, and varicella virus vaccine
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text ProQuad
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 01
RXA.9.2 Text historical
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 7W27V7491
RXA.16 Substance Expiration Date
RXA.16.1 Time 20101215
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier MSD
RXA.17.2 Text Merck Sharp \T\ Dohme Corp
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 32
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20121122
RXA.5 Administered Code
RXA.5.1 Identifier 94
RXA.5.2 Text measles, mumps, rubella, and varicella virus vaccine
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text ProQuad
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 7W87V3452
RXA.16 Substance Expiration Date
RXA.16.1 Time 20130413
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier MSD
RXA.17.2 Text Merck Sharp \T\ Dohme Corp
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 33
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20150715
RXA.5 Administered Code
RXA.5.1 Identifier 94 Test Case Fixed
RXA.5.2 Text measles, mumps, rubella, and varicella virus vaccine Test Case Fixed
RXA.5.3 Name of Coding System CVX Test Case Fixed
RXA.5.5 Alternate Text ProQuad Test Case Fixed
RXA.5.6 Name of Alternate Coding System NDC Test Case Fixed
RXA.6 Administered Amount 0.5 Test Case Fixed
RXA.7 Administered Units
RXA.7.1 Identifier mL Test Case Fixed
RXA.7.2 Text
RXA.7.3 Name of Coding System UCUM Test Case Fixed
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 00 Test Case Fixed
RXA.9.2 Text New immunization record Test Case Fixed
RXA.9.3 Name of Coding System NIP001 Test Case Fixed
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Molina Test Case Fixed
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name Sandra Test Case Fixed
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 7W87V3687 Test Case Fixed
RXA.16 Substance Expiration Date
RXA.16.1 Time 20150715 Test Case Fixed
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier MSD Test Case Fixed
RXA.17.2 Text Merck Sharp \T\ Dohme Corp Test Case Fixed
RXA.17.3 Name of Coding System MVX Test Case Fixed
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP Test Case Fixed
RXA.21 Action Code - RXA A

RXR[*]
RXR - 1
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 2
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier RT
RXR.2.2 Text Right Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 3
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 4
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 5
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier RT
RXR.2.2 Text Right Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 6
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 7
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 8
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 9
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier RT
RXR.2.2 Text Right Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 10
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 11
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier RT
RXR.2.2 Text Right Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 12
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 13
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C38299
RXR.1.2 Text SC
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text Subcutaneous
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 14
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C38299
RXR.1.2 Text SC
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text Subcutaneous
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 15
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C38299
RXR.1.2 Text SC
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text Subcutaneous
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 16
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 17
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C38299
RXR.1.2 Text SC
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text Subcutaneous
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 18
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier RT
RXR.2.2 Text Right Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 19
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 20
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 21
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier RT
RXR.2.2 Text Right Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 22
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 23
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier RT
RXR.2.2 Text Right Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 24
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 25
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C38284
RXR.1.2 Text Nasal
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text Nasal
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier BN
RXR.2.2 Text Bilateral Nares
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 26
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C38284
RXR.1.2 Text Nasal
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text Nasal
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier BN
RXR.2.2 Text Bilateral Nares
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 27
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 28
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier RD
RXR.2.2 Text Right Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 29
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 30
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C38299
RXR.1.2 Text Subcutaneous
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text Subcutaneous
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 31
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C38299
RXR.1.2 Text Subcutaneous
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text Subcutaneous
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 32
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C38299 Test Case Fixed
RXR.1.2 Text Subcutaneous Test Case Fixed
RXR.1.3 Name of Coding System NCIT Test Case Fixed
RXR.1.5 Alternate Text Subcutaneous Test Case Fixed
RXR.1.6 Name of Alternate Coding System HL70162 Test Case Fixed
RXR.2 Administration Site
RXR.2.1 Identifier LD Test Case Fixed
RXR.2.2 Text Left Deltoid Test Case Fixed
RXR.2.3 Name of Coding System HL70163 Test Case Fixed
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

OBX[*]
OBX - 1
Location Data Element Data Categorization
OBX.1 Set ID - OBX 21
OBX.2 Value Type CE
OBX.3 Observation Identifier
OBX.3.1 Identifier 31044-1
OBX.3.2 Text Reaction
OBX.3.3 Name of Coding System LN
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20100522
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 2
Location Data Element Data Categorization
OBX.1 Set ID - OBX 2
OBX.2 Value Type TS
OBX.3 Observation Identifier
OBX.3.1 Identifier 29768-9
OBX.3.2 Text VIS Publication Date
OBX.3.3 Name of Coding System LN
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.5.1 Time 20140819
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 3
Location Data Element Data Categorization
OBX.1 Set ID - OBX 3
OBX.2 Value Type TS
OBX.3 Observation Identifier
OBX.3.1 Identifier 29769-7
OBX.3.2 Text VIS Presentation Date
OBX.3.3 Name of Coding System LN
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.5.1 Time 20150715
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 4
Location Data Element Data Categorization
OBX.1 Set ID - OBX 1
OBX.2 Value Type CE
OBX.3 Observation Identifier
OBX.3.1 Identifier 64994-7
OBX.3.2 Text vaccine fund pgm elig cat
OBX.3.3 Name of Coding System LN
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 5
Location Data Element Data Categorization
OBX.1 Set ID - OBX 2
OBX.2 Value Type TS
OBX.3 Observation Identifier
OBX.3.1 Identifier 29768-9
OBX.3.2 Text VIS Publication Date
OBX.3.3 Name of Coding System LN
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.5.1 Time 20100521
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 6
Location Data Element Data Categorization
OBX.1 Set ID - OBX 3
OBX.2 Value Type TS
OBX.3 Observation Identifier
OBX.3.1 Identifier 29769-7
OBX.3.2 Text VIS Presentation Date
OBX.3.3 Name of Coding System LN
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.5.1 Time 20150715
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 7
Location Data Element Data Categorization
OBX.1 Set ID - OBX 1
OBX.2 Value Type CE
OBX.3 Observation Identifier
OBX.3.1 Identifier 64994-7
OBX.3.2 Text vaccine fund pgm elig cat
OBX.3.3 Name of Coding System LN
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 8
Location Data Element Data Categorization
OBX.1 Set ID - OBX 1
OBX.2 Value Type CE
OBX.3 Observation Identifier
OBX.3.1 Identifier 64994-7
OBX.3.2 Text vaccine fund pgm elig cat
OBX.3.3 Name of Coding System LN
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 9
Location Data Element Data Categorization
OBX.1 Set ID - OBX 21
OBX.2 Value Type CE
OBX.3 Observation Identifier
OBX.3.1 Identifier 31044-1 Test Case Fixed
OBX.3.2 Text Reaction Test Case Fixed
OBX.3.3 Name of Coding System LN Test Case Fixed
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

Location Data Element Data Categorization
MSH.1 Field Separator |
MSH.2 Encoding Characters ^~\&
MSH.3 Sending Application
MSH.3.1 Namespace ID Test EHR Application
MSH.3.2 Universal ID
MSH.3.3 Universal ID Type
MSH.4 Sending Facility
MSH.4.1 Namespace ID X68
MSH.4.2 Universal ID
MSH.4.3 Universal ID Type
MSH.5 Receiving Application
MSH.5.1 Namespace ID
MSH.5.2 Universal ID
MSH.5.3 Universal ID Type
MSH.6 Receiving Facility
MSH.6.1 Namespace ID NIST Test Iz Reg
MSH.6.2 Universal ID
MSH.6.3 Universal ID Type
MSH.7 Date/Time Of Message
MSH.7.1 Time 20120701082240-0500
MSH.9 Message Type
MSH.9.1 Message Code VXU
MSH.9.2 Trigger Event V04
MSH.9.3 Message Structure VXU_V04
MSH.10 Message Control ID NIST-IZ-001.00
MSH.11 Processing ID
MSH.11.1 Processing ID P
MSH.12 Version ID
MSH.12.1 Version ID 2.5.1
MSH.15 Accept Acknowledgment Type ER
MSH.16 Application Acknowledgment Type AL
MSH.21 Message Profile Identifier
MSH.21.1 Entity Identifier Z22
MSH.21.2 Namespace ID CDCPHINVS
MSH.21.3 Universal ID
MSH.21.4 Universal ID Type
MSH.22 Sending Responsible Organization
MSH.22.1 Organization Name
MSH.22.6 Assigning Authority
MSH.22.6.1 Namespace ID
MSH.22.6.2 Universal ID
MSH.22.6.3 Universal ID Type
MSH.22.7 Identifier Type Code
MSH.22.10 Organization Identifier
MSH.23 Receiving Responsible Organization
MSH.23.1 Organization Name
MSH.23.6 Assigning Authority
MSH.23.6.1 Namespace ID
MSH.23.6.2 Universal ID
MSH.23.6.3 Universal ID Type
MSH.23.7 Identifier Type Code
MSH.23.10 Organization Identifier

Location Data Element Data Categorization
PID.1 Set ID - PID 1
PID.3 Patient Identifier List
PID.3.1 ID Number 123456
PID.3.3 Check Digit Scheme
PID.3.4 Assigning Authority
PID.3.4.1 Namespace ID MYEHR
PID.3.4.2 Universal ID
PID.3.4.3 Universal ID Type
PID.3.5 Identifier Type Code MR
PID.3 Patient Identifier List
PID.3.1 ID Number 987633
PID.3.3 Check Digit Scheme
PID.3.4 Assigning Authority
PID.3.4.1 Namespace ID MYIIS
PID.3.4.2 Universal ID
PID.3.4.3 Universal ID Type
PID.3.5 Identifier Type Code SR
PID.5 Patient Name
PID.5.1 Family Name
PID.5.1.1 Surname Gonzales Test Case Fixed
PID.5.1.2 Own Surname Prefix
PID.5.1.3 Own Surname
PID.5.1.4 Surname Prefix From Partner/Spouse
PID.5.1.5 Surname From Partner/Spouse
PID.5.2 Given Name Juana Test Case Fixed
PID.5.3 Second and Further Given Names or Initials Thereof Mariana Test Case Fixed
PID.5.7 Name Type Code L Test Case Fixed
PID.6 Mother's Maiden Name
PID.6.1 Family Name
PID.6.1.1 Surname Acosta Test Case Fixed
PID.6.1.2 Own Surname Prefix
PID.6.1.3 Own Surname
PID.6.1.4 Surname Prefix From Partner/Spouse
PID.6.1.5 Surname From Partner/Spouse
PID.6.7 Name Type Code M Test Case Fixed
PID.7 Date/Time of Birth
PID.7.1 Time 200912231105 Test Case Fixed
PID.8 Administrative Sex F Test Case Fixed
PID.10 Race
PID.10.1 Identifier 2131-1 Test Case Fixed
PID.10.2 Text Other Race Test Case Fixed
PID.10.3 Name of Coding System HL70005 Test Case Fixed
PID.10.5 Alternate Text
PID.10.6 Name of Alternate Coding System
PID.11 Patient Address
PID.11.1 Street Address
PID.11.1.1 Street or Mailing Address 4345 Standish Way Test Case Fixed
PID.11.1.2 Street Name
PID.11.1.3 Dwelling Number
PID.11.2 Other Designation
PID.11.3 City Stamford Test Case Fixed
PID.11.4 State or Province CT Test Case Fixed
PID.11.5 Zip or Postal Code 06903 Test Case Fixed
PID.11.6 Country USA Test Case Fixed
PID.11.7 Address Type L Test Case Fixed
PID.11 Patient Address
PID.11.1 Street Address
PID.11.1.1 Street or Mailing Address 325 Shorline Drive
PID.11.1.2 Street Name
PID.11.1.3 Dwelling Number
PID.11.2 Other Designation
PID.11.3 City Stamford
PID.11.4 State or Province CT Test Case Fixed
PID.11.5 Zip or Postal Code 06901
PID.11.6 Country
PID.11.7 Address Type BDL Test Case Fixed
PID.13 Phone Number - Home
PID.13.2 Telecommunication Use Code PRN Test Case Fixed
PID.13.3 Telecommunication Equipment Type PH Test Case Fixed
PID.13.4 Email Address
PID.13.6 Area/City Code 203 Test Case Fixed
PID.13.7 Local Number 5551212 Test Case Fixed
PID.22 Ethnic Group
PID.22.1 Identifier 2135-2 Test Case Fixed
PID.22.2 Text Hispanic or Latino Test Case Fixed
PID.22.3 Name of Coding System CDCREC Test Case Fixed
PID.22.5 Alternate Text
PID.22.6 Name of Alternate Coding System
PID.24 Multiple Birth Indicator
PID.25 Birth Order
PID.29 Patient Death Date and Time
PID.29.1 Time
PID.30 Patient Death Indicator

Location Data Element Data Categorization
PD1.11 Publicity Code
PD1.11.1 Identifier 02
PD1.11.2 Text Reminder/Recall - any method
PD1.11.3 Name of Coding System HL70215
PD1.11.5 Alternate Text
PD1.11.6 Name of Alternate Coding System
PD1.12 Protection Indicator
PD1.13 Protection Indicator Effective Date
PD1.16 Immunization Registry Status A
PD1.17 Immunization Registry Status Effective Date 20120701
PD1.18 Publicity Code Effective Date 20120701

Location Data Element Data Categorization
NK1.1 Set ID - NK1 1
NK1.2 Name
NK1.2.1 Family Name
NK1.2.1.1 Surname Gonzales
NK1.2.1.2 Own Surname Prefix
NK1.2.1.3 Own Surname
NK1.2.1.4 Surname Prefix From Partner/Spouse
NK1.2.1.5 Surname From Partner/Spouse
NK1.2.2 Given Name Joanna Test Case Fixed
NK1.2.3 Second and Further Given Names or Initials Thereof Merida Test Case Fixed
NK1.2.7 Name Type Code L Test Case Fixed
NK1.3 Relationship
NK1.3.1 Identifier GRP Test Case Fixed
NK1.3.2 Text Grandparent Test Case Fixed
NK1.3.3 Name of Coding System HL70063 Test Case Fixed
NK1.3.5 Alternate Text
NK1.3.6 Name of Alternate Coding System
NK1.4 Address
NK1.4.1 Street Address
NK1.4.1.1 Street or Mailing Address 4345 Standish Way Test Case Fixed
NK1.4.1.2 Street Name
NK1.4.1.3 Dwelling Number
NK1.4.2 Other Designation
NK1.4.3 City Stamford Test Case Fixed
NK1.4.4 State or Province CT Test Case Fixed
NK1.4.5 Zip or Postal Code 06901 Test Case Fixed
NK1.4.6 Country
NK1.4.7 Address Type L Test Case Fixed
NK1.5 Phone Number
NK1.5.2 Telecommunication Use Code PRN Test Case Fixed
NK1.5.3 Telecommunication Equipment Type PH Test Case Fixed
NK1.5.4 Email Address
NK1.5.6 Area/City Code 203 Test Case Fixed
NK1.5.7 Local Number 5551212 Test Case Fixed

ORC - 1
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Sirtis
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name Lisa
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Carter
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Jane
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier SH
ORC.17.2 Text Shoreline Hospital
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 2
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Molina
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name Sandra
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Smith
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Frank
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier SP
ORC.17.2 Text Shoreline Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 3
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 4
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 5
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 6
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L Test Case Fixed
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 7
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 8
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Molina
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name Sandra
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier SP
ORC.17.2 Text Shoreline Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 9
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 10
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 11
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 12
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 13
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 14
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 15
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Molina
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name Sandra
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier SP
ORC.17.2 Text Shoreline Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 16
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 9999
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Molina
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name Sandra
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Smith
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Frank
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier SP
ORC.17.2 Text Shoreline Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 17
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 18
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 19
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 20
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 21
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 22
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 23
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 24
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 25
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 26
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Molina
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name Sandra
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Ricci
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Gina
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier SP
ORC.17.2 Text Shoreline Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 27
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Molina
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name Sandra
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Smith
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Frank
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier SP
ORC.17.2 Text Shoreline Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 28
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 29
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Herrera
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Carlos
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 30
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Smith
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name F
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 31
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Smith
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name F
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 32
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Smith
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name F
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 33
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Molina Test Case Fixed
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name Sandra Test Case Fixed
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Smith Test Case Fixed
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Frank Test Case Fixed
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L Test Case Fixed
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier SP
ORC.17.2 Text Shoreline Pediatrics Test Case Fixed
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

RXA - 1
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20091123
RXA.5 Administered Code
RXA.5.1 Identifier 08
RXA.5.2 Text hepatitis B vaccine, pediatric or pediatric/adolescent dosage
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text ENGERIX-B
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Sirtis
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name Lisa
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 6332FK33
RXA.16 Substance Expiration Date
RXA.16.1 Time 20101214
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier SKB
RXA.17.2 Text GlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 2
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100115
RXA.5 Administered Code
RXA.5.1 Identifier 45
RXA.5.2 Text hepatitis B vaccine, unspecified formulation
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text ENGERIX-B
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 01
RXA.9.2 Text Historical Immunization
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Molina
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name Sandra
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 6352FK1
RXA.16 Substance Expiration Date
RXA.16.1 Time 20101001
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier SKB
RXA.17.2 Text GlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 3
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20101030
RXA.5 Administered Code
RXA.5.1 Identifier 08
RXA.5.2 Text hepatitis B vaccine, pediatric or pediatric/adolescent dosage
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text ENGERIX-B
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 6352FK24
RXA.16 Substance Expiration Date
RXA.16.1 Time 20120831
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier SKB
RXA.17.2 Text GlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 4
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100122
RXA.5 Administered Code
RXA.5.1 Identifier 107
RXA.5.2 Text diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text DAPTACEL
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D409QS2341
RXA.16 Substance Expiration Date
RXA.16.1 Time 20111130
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi Pasteur Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 5
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100323
RXA.5 Administered Code
RXA.5.1 Identifier 106
RXA.5.2 Text diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text DAPTACEL
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D409QS2433
RXA.16 Substance Expiration Date
RXA.16.1 Time 20110904
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi Pasteur Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 6
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100522
RXA.5 Administered Code
RXA.5.1 Identifier 106
RXA.5.2 Text diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text DAPTACEL
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D409QS3255
RXA.16 Substance Expiration Date
RXA.16.1 Time 20101201
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi Pasteur Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 7
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20110221
RXA.5 Administered Code
RXA.5.1 Identifier 106
RXA.5.2 Text diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text DAPTACEL
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D409QS249
RXA.16 Substance Expiration Date
RXA.16.1 Time 20110301
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi Pasteur Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 8
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20140831
RXA.5 Administered Code
RXA.5.1 Identifier 106
RXA.5.2 Text diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text DAPTACEL
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 02
RXA.9.2 Text Historical information - from other provider
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Casera
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name Linda
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D643QS8243
RXA.16 Substance Expiration Date
RXA.16.1 Time 20140901
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi Pasteur Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 9
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100122
RXA.5 Administered Code
RXA.5.1 Identifier 49
RXA.5.2 Text Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text PedvaxHIB
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 7M54K9245
RXA.16 Substance Expiration Date
RXA.16.1 Time 20100324
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier MSD
RXA.17.2 Text Merck Sharp \T\ Dohme Corp
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 10
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100323
RXA.5 Administered Code
RXA.5.1 Identifier 49
RXA.5.2 Text Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text PedvaxHIB
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 7M55K3342
RXA.16 Substance Expiration Date
RXA.16.1 Time 20101030
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier MSD
RXA.17.2 Text Merck Sharp \T\ Dohme Corp
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 11
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100522
RXA.5 Administered Code
RXA.5.1 Identifier 49
RXA.5.2 Text Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text PedvaxHIB
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 7M75K4566
RXA.16 Substance Expiration Date
RXA.16.1 Time 20100523
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier MSD
RXA.17.2 Text Merck Sharp \T\ Dohme Corp
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 12
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20110221
RXA.5 Administered Code
RXA.5.1 Identifier 49
RXA.5.2 Text Haemophilus influenzae type b vaccine, PRP-OMP conjugate
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text PedvaxHIB
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 7M53K5534
RXA.16 Substance Expiration Date
RXA.16.1 Time 20110222
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier MSD
RXA.17.2 Text Merck Sharp \T\ Dohme Corp
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 13
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100122
RXA.5 Administered Code
RXA.5.1 Identifier 10
RXA.5.2 Text poliovirus vaccine, inactivated
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text IPOL
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D333PV2431
RXA.16 Substance Expiration Date
RXA.16.1 Time 20101004
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi Pasteur Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 14
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100323
RXA.5 Administered Code
RXA.5.1 Identifier 10
RXA.5.2 Text poliovirus vaccine, inactivated
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text IPOL
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D333PV4344
RXA.16 Substance Expiration Date
RXA.16.1 Time 20100323
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi Pasteur Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 15
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20110221
RXA.5 Administered Code
RXA.5.1 Identifier 10
RXA.5.2 Text poliovirus vaccine, inactivated
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text IPOL
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 02
RXA.9.2 Text Historical information - from other provider
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Casera
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name Linda
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D335PV9644
RXA.16 Substance Expiration Date
RXA.16.1 Time 20110222
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi Pasteur Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 16
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20150519
RXA.5 Administered Code
RXA.5.1 Identifier 10
RXA.5.2 Text poliovirus vaccine, inactivated
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text
RXA.5.6 Name of Alternate Coding System
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier
RXA.9.2 Text
RXA.9.3 Name of Coding System
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number
RXA.16 Substance Expiration Date
RXA.16.1 Time
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier
RXA.17.2 Text
RXA.17.3 Name of Coding System
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier 00
RXA.18.2 Text Parental decision
RXA.18.3 Name of Coding System NIP002
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status RE
RXA.21 Action Code - RXA A

RXA - 17
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100121
RXA.5 Administered Code
RXA.5.1 Identifier 133
RXA.5.2 Text pneumococcal conjugate vaccine, 13 valent
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text PREVNAR 13
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number P243V3281
RXA.16 Substance Expiration Date
RXA.16.1 Time 20100130
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PFR
RXA.17.2 Text Pfizer, Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 18
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100323
RXA.5 Administered Code
RXA.5.1 Identifier 133
RXA.5.2 Text pneumococcal conjugate vaccine, 13 valent
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text PREVNAR 13
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number P343V8321
RXA.16 Substance Expiration Date
RXA.16.1 Time 20100330
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PFR
RXA.17.2 Text Pfizer, Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 19
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100522
RXA.5 Administered Code
RXA.5.1 Identifier 133
RXA.5.2 Text pneumococcal conjugate vaccine, 13 valent
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text PREVNAR 13
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number P853V2164
RXA.16 Substance Expiration Date
RXA.16.1 Time 20100830
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PFR
RXA.17.2 Text Pfizer, Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 20
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20110221
RXA.5 Administered Code
RXA.5.1 Identifier 133
RXA.5.2 Text pneumococcal conjugate vaccine, 13 valent
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text PREVNAR 13
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number P853V58532
RXA.16 Substance Expiration Date
RXA.16.1 Time 20110418
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PFR
RXA.17.2 Text Pfizer, Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 21
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100122
RXA.5 Administered Code
RXA.5.1 Identifier 119
RXA.5.2 Text rotavirus, live, monovalent vaccine
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text ROTARIX
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 6359RV533
RXA.16 Substance Expiration Date
RXA.16.1 Time 20100215
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier SKB
RXA.17.2 Text GlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 22
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100323
RXA.5 Administered Code
RXA.5.1 Identifier 119
RXA.5.2 Text rotavirus, live, monovalent vaccine
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text ROTARIX
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 6359RV932
RXA.16 Substance Expiration Date
RXA.16.1 Time 20100510
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier SKB
RXA.17.2 Text GlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 23
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20100925
RXA.5 Administered Code
RXA.5.1 Identifier 161
RXA.5.2 Text Influenza, injectable,quadrivalent, preservative free, pediatric
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text FLUZONE QUADRIVALENT
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D8043IN8734
RXA.16 Substance Expiration Date
RXA.16.1 Time 20110312
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 24
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20101027
RXA.5 Administered Code
RXA.5.1 Identifier 161
RXA.5.2 Text Influenza, injectable,quadrivalent, preservative free, pediatric
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text FLUZONE QUADRIVALENT
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D8043IN8734
RXA.16 Substance Expiration Date
RXA.16.1 Time 20110312
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 25
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20111002
RXA.5 Administered Code
RXA.5.1 Identifier 161
RXA.5.2 Text Influenza, injectable,quadrivalent, preservative free, pediatric
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text FLUZONE QUADRIVALENT
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D9334IN9333
RXA.16 Substance Expiration Date
RXA.16.1 Time 20120522
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 26
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20131015
RXA.5 Administered Code
RXA.5.1 Identifier 161
RXA.5.2 Text Influenza, injectable,quadrivalent, preservative free, pediatric
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text FLUZONE QUADRIVALENT
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 03
RXA.9.2 Text Historical information - from parents written record
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Ricci
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name Gina
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 8L4B3423
RXA.16 Substance Expiration Date
RXA.16.1 Time 20140701
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier MED
RXA.17.2 Text MedImmune, LLC
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 27
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20150715
RXA.5 Administered Code
RXA.5.1 Identifier 149
RXA.5.2 Text influenza, live, intranasal, quadrivalent
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text FluMist Quadrivalent
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 0.2
RXA.7 Administered Units
RXA.7.1 Identifier mL
RXA.7.2 Text
RXA.7.3 Name of Coding System UCUM
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 00
RXA.9.2 Text New immunization record
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Molina
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name Sandra
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 8L4B3521
RXA.16 Substance Expiration Date
RXA.16.1 Time 20150815
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier MED
RXA.17.2 Text MedImmune,LLC
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 28
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20121104
RXA.5 Administered Code
RXA.5.1 Identifier 149
RXA.5.2 Text influenza, live, intranasal, quadrivalent
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text FluMist Quadrivalent
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D9553IN2243
RXA.16 Substance Expiration Date
RXA.16.1 Time 20120430
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 29
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20111123
RXA.5 Administered Code
RXA.5.1 Identifier 83
RXA.5.2 Text hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text HAVRIX
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 6359RT33
RXA.16 Substance Expiration Date
RXA.16.1 Time 20120124
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier SKB
RXA.17.2 Text GlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 30
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20120523
RXA.5 Administered Code
RXA.5.1 Identifier 83
RXA.5.2 Text hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text HAVRIX
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 6359RT48
RXA.16 Substance Expiration Date
RXA.16.1 Time 20120911
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi PasteurGlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 31
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20101023
RXA.5 Administered Code
RXA.5.1 Identifier 94
RXA.5.2 Text measles, mumps, rubella, and varicella virus vaccine
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text ProQuad
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 01
RXA.9.2 Text historical
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 7W27V7491
RXA.16 Substance Expiration Date
RXA.16.1 Time 20101215
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier MSD
RXA.17.2 Text Merck Sharp \T\ Dohme Corp
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 32
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20121122
RXA.5 Administered Code
RXA.5.1 Identifier 94
RXA.5.2 Text measles, mumps, rubella, and varicella virus vaccine
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text ProQuad
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 7W87V3452
RXA.16 Substance Expiration Date
RXA.16.1 Time 20130413
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier MSD
RXA.17.2 Text Merck Sharp \T\ Dohme Corp
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 33
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20150715
RXA.5 Administered Code
RXA.5.1 Identifier 94 Test Case Fixed
RXA.5.2 Text measles, mumps, rubella, and varicella virus vaccine Test Case Fixed
RXA.5.3 Name of Coding System CVX Test Case Fixed
RXA.5.5 Alternate Text ProQuad Test Case Fixed
RXA.5.6 Name of Alternate Coding System NDC Test Case Fixed
RXA.6 Administered Amount 0.5 Test Case Fixed
RXA.7 Administered Units
RXA.7.1 Identifier mL Test Case Fixed
RXA.7.2 Text
RXA.7.3 Name of Coding System UCUM Test Case Fixed
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 00 Test Case Fixed
RXA.9.2 Text New immunization record Test Case Fixed
RXA.9.3 Name of Coding System NIP001 Test Case Fixed
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Molina Test Case Fixed
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name Sandra Test Case Fixed
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 7W87V3687 Test Case Fixed
RXA.16 Substance Expiration Date
RXA.16.1 Time 20150715 Test Case Fixed
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier MSD Test Case Fixed
RXA.17.2 Text Merck Sharp \T\ Dohme Corp Test Case Fixed
RXA.17.3 Name of Coding System MVX Test Case Fixed
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP Test Case Fixed
RXA.21 Action Code - RXA A

RXR - 1
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 2
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier RT
RXR.2.2 Text Right Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 3
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 4
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 5
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier RT
RXR.2.2 Text Right Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 6
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 7
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 8
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 9
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier RT
RXR.2.2 Text Right Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 10
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 11
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier RT
RXR.2.2 Text Right Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 12
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 13
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C38299
RXR.1.2 Text SC
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text Subcutaneous
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 14
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C38299
RXR.1.2 Text SC
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text Subcutaneous
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 15
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C38299
RXR.1.2 Text SC
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text Subcutaneous
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 16
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 17
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C38299
RXR.1.2 Text SC
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text Subcutaneous
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 18
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier RT
RXR.2.2 Text Right Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 19
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 20
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 21
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier RT
RXR.2.2 Text Right Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 22
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 23
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier RT
RXR.2.2 Text Right Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 24
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 25
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C38284
RXR.1.2 Text Nasal
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text Nasal
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier BN
RXR.2.2 Text Bilateral Nares
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 26
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C38284
RXR.1.2 Text Nasal
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text Nasal
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier BN
RXR.2.2 Text Bilateral Nares
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 27
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 28
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier RD
RXR.2.2 Text Right Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 29
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 30
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C38299
RXR.1.2 Text Subcutaneous
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text Subcutaneous
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 31
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C38299
RXR.1.2 Text Subcutaneous
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text Subcutaneous
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 32
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C38299 Test Case Fixed
RXR.1.2 Text Subcutaneous Test Case Fixed
RXR.1.3 Name of Coding System NCIT Test Case Fixed
RXR.1.5 Alternate Text Subcutaneous Test Case Fixed
RXR.1.6 Name of Alternate Coding System HL70162 Test Case Fixed
RXR.2 Administration Site
RXR.2.1 Identifier LD Test Case Fixed
RXR.2.2 Text Left Deltoid Test Case Fixed
RXR.2.3 Name of Coding System HL70163 Test Case Fixed
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

OBX - 1
Location Data Element Data Categorization
OBX.1 Set ID - OBX 21
OBX.2 Value Type CE
OBX.3 Observation Identifier
OBX.3.1 Identifier 31044-1
OBX.3.2 Text Reaction
OBX.3.3 Name of Coding System LN
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20100522
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 2
Location Data Element Data Categorization
OBX.1 Set ID - OBX 2
OBX.2 Value Type TS
OBX.3 Observation Identifier
OBX.3.1 Identifier 29768-9
OBX.3.2 Text VIS Publication Date
OBX.3.3 Name of Coding System LN
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.5.1 Time 20140819
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 3
Location Data Element Data Categorization
OBX.1 Set ID - OBX 3
OBX.2 Value Type TS
OBX.3 Observation Identifier
OBX.3.1 Identifier 29769-7
OBX.3.2 Text VIS Presentation Date
OBX.3.3 Name of Coding System LN
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.5.1 Time 20150715
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 4
Location Data Element Data Categorization
OBX.1 Set ID - OBX 1
OBX.2 Value Type CE
OBX.3 Observation Identifier
OBX.3.1 Identifier 64994-7
OBX.3.2 Text vaccine fund pgm elig cat
OBX.3.3 Name of Coding System LN
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 5
Location Data Element Data Categorization
OBX.1 Set ID - OBX 2
OBX.2 Value Type TS
OBX.3 Observation Identifier
OBX.3.1 Identifier 29768-9
OBX.3.2 Text VIS Publication Date
OBX.3.3 Name of Coding System LN
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.5.1 Time 20100521
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 6
Location Data Element Data Categorization
OBX.1 Set ID - OBX 3
OBX.2 Value Type TS
OBX.3 Observation Identifier
OBX.3.1 Identifier 29769-7
OBX.3.2 Text VIS Presentation Date
OBX.3.3 Name of Coding System LN
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.5.1 Time 20150715
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 7
Location Data Element Data Categorization
OBX.1 Set ID - OBX 1
OBX.2 Value Type CE
OBX.3 Observation Identifier
OBX.3.1 Identifier 64994-7
OBX.3.2 Text vaccine fund pgm elig cat
OBX.3.3 Name of Coding System LN
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 8
Location Data Element Data Categorization
OBX.1 Set ID - OBX 1
OBX.2 Value Type CE
OBX.3 Observation Identifier
OBX.3.1 Identifier 64994-7
OBX.3.2 Text vaccine fund pgm elig cat
OBX.3.3 Name of Coding System LN
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 9
Location Data Element Data Categorization
OBX.1 Set ID - OBX 21
OBX.2 Value Type CE
OBX.3 Observation Identifier
OBX.3.1 Identifier 31044-1 Test Case Fixed
OBX.3.2 Text Reaction Test Case Fixed
OBX.3.3 Name of Coding System LN Test Case Fixed
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

Test Data Specification

Patient Information
Element Data
Patient Name Juana Mariana Gonzales
Mother's Maiden Name Maria Acosta
ID Number 123456 987633
Date/Time of Birth 12/23/2009
Administrative Sex Female
Patient Address 4345 Standish Way Stamford CT 06903 USA
Patient Address 1 325 Shorline Drive Stamford CT 06901
Local Number (203)555-1212
Race Other Race
Ethnic Group Hispanic or Latino
Birth Order
Immunization Registry Information
Element Data
Immunization Registry Status A
Immunization Registry Status Effective Date 07/01/2012
Publicity Code Reminder/Recall - any method
Publicity Code Effective Date 07/01/2012
Protection Indicator
Protection Indicator Effective Date
Guardian or Responsible Party
Element Data
Name Joanna Merida Gonzales
Relationship Grandparent
Address 4345 Standish Way Stamford CT 06901
Phone Number (203)555-1212

Vaccine Administration Information[*]
Vaccine Administration Information - 1
Element Data
Administered Code hepatitis B vaccine, pediatric or pediatric/adolescent dosage
Date/Time Start of Administration 11/23/2009
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider Lisa Sirtis
Substance Lot Number 6332FK33
Substance Expiration Date 12/14/2010
Substance Manufacturer Name GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Thigh
Entering Organization Shoreline Hospital
Entered By Lisa Sirtis
Ordered By Jane Carter

Vaccine Administration Information - 2
Element Data
Administered Code hepatitis B vaccine, unspecified formulation
Date/Time Start of Administration 01/15/2010
Administered Amount 999
Administered Units
Administration Notes Historical Immunization
Administering Provider Sandra Molina
Substance Lot Number 6352FK1
Substance Expiration Date 10/01/2010
Substance Manufacturer Name GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Right Thigh
Entering Organization Shoreline Pediatrics
Entered By Sandra Molina
Ordered By Frank Smith

Vaccine Administration Information - 3
Element Data
Administered Code hepatitis B vaccine, pediatric or pediatric/adolescent dosage
Date/Time Start of Administration 10/30/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number 6352FK24
Substance Expiration Date 08/31/2012
Substance Manufacturer Name GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

Vaccine Administration Information - 4
Element Data
Administered Code diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Date/Time Start of Administration 01/22/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number D409QS2341
Substance Expiration Date 11/30/2011
Substance Manufacturer Name Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

Vaccine Administration Information - 5
Element Data
Administered Code diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Date/Time Start of Administration 03/23/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number D409QS2433
Substance Expiration Date 09/04/2011
Substance Manufacturer Name Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Right Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

Vaccine Administration Information - 6
Element Data
Administered Code diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Date/Time Start of Administration 05/22/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number D409QS3255
Substance Expiration Date 12/01/2010
Substance Manufacturer Name Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

Historical information - from public agency
Element Data
Reaction fever of >40.5C (105F) within 48 hours of dose

Vaccine Administration Information - 7
Element Data
Administered Code diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Date/Time Start of Administration 02/21/2011
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number D409QS249
Substance Expiration Date 03/01/2011
Substance Manufacturer Name Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

Vaccine Administration Information - 8
Element Data
Administered Code diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Date/Time Start of Administration 08/31/2014
Administered Amount 999
Administered Units
Administration Notes Historical information - from other provider
Administering Provider Linda Casera
Substance Lot Number D643QS8243
Substance Expiration Date 09/01/2014
Substance Manufacturer Name Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Deltoid
Entering Organization Shoreline Pediatrics
Entered By Sandra Molina
Ordered By J Rodriguez

Vaccine Administration Information - 9
Element Data
Administered Code Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Date/Time Start of Administration 01/22/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number 7M54K9245
Substance Expiration Date 03/24/2010
Substance Manufacturer Name Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Right Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

Vaccine Administration Information - 10
Element Data
Administered Code Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Date/Time Start of Administration 03/23/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number 7M55K3342
Substance Expiration Date 10/30/2010
Substance Manufacturer Name Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

Vaccine Administration Information - 11
Element Data
Administered Code Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Date/Time Start of Administration 05/22/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number 7M75K4566
Substance Expiration Date 05/23/2010
Substance Manufacturer Name Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Right Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

Vaccine Administration Information - 12
Element Data
Administered Code Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Date/Time Start of Administration 02/21/2011
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number 7M53K5534
Substance Expiration Date 02/22/2011
Substance Manufacturer Name Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

Vaccine Administration Information - 13
Element Data
Administered Code poliovirus vaccine, inactivated
Date/Time Start of Administration 01/22/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number D333PV2431
Substance Expiration Date 10/04/2010
Substance Manufacturer Name Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route SC
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

Vaccine Administration Information - 14
Element Data
Administered Code poliovirus vaccine, inactivated
Date/Time Start of Administration 03/23/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number D333PV4344
Substance Expiration Date 03/23/2010
Substance Manufacturer Name Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route SC
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

Vaccine Administration Information - 15
Element Data
Administered Code poliovirus vaccine, inactivated
Date/Time Start of Administration 02/21/2011
Administered Amount 999
Administered Units
Administration Notes Historical information - from other provider
Administering Provider Linda Casera
Substance Lot Number D335PV9644
Substance Expiration Date 02/22/2011
Substance Manufacturer Name Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route SC
Administration Site Left Deltoid
Entering Organization Shoreline Pediatrics
Entered By Sandra Molina
Ordered By J Rodriguez

Vaccine Administration Information - 16
Element Data
Administered Code poliovirus vaccine, inactivated
Date/Time Start of Administration 05/19/2015
Administered Amount 999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason Parental decision
Completion Status RE
Action Code Add
Route
Administration Site
Entering Organization Shoreline Pediatrics
Entered By Sandra Molina
Ordered By Frank Smith

Vaccine Administration Information - 17
Element Data
Administered Code pneumococcal conjugate vaccine, 13 valent
Date/Time Start of Administration 01/21/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number P243V3281
Substance Expiration Date 01/30/2010
Substance Manufacturer Name Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

Vaccine Administration Information - 18
Element Data
Administered Code pneumococcal conjugate vaccine, 13 valent
Date/Time Start of Administration 03/23/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number P343V8321
Substance Expiration Date 03/30/2010
Substance Manufacturer Name Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route SC
Administration Site Left Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

Vaccine Administration Information - 19
Element Data
Administered Code pneumococcal conjugate vaccine, 13 valent
Date/Time Start of Administration 05/22/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number P853V2164
Substance Expiration Date 08/30/2010
Substance Manufacturer Name Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Right Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

Vaccine Administration Information - 20
Element Data
Administered Code pneumococcal conjugate vaccine, 13 valent
Date/Time Start of Administration 02/21/2011
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number P853V58532
Substance Expiration Date 04/18/2011
Substance Manufacturer Name Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

Vaccine Administration Information - 21
Element Data
Administered Code rotavirus, live, monovalent vaccine
Date/Time Start of Administration 01/22/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number 6359RV533
Substance Expiration Date 02/15/2010
Substance Manufacturer Name GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

Vaccine Administration Information - 22
Element Data
Administered Code rotavirus, live, monovalent vaccine
Date/Time Start of Administration 03/23/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number 6359RV932
Substance Expiration Date 05/10/2010
Substance Manufacturer Name GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Right Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

Vaccine Administration Information - 23
Element Data
Administered Code Influenza, injectable,quadrivalent, preservative free, pediatric
Date/Time Start of Administration 09/25/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number D8043IN8734
Substance Expiration Date 03/12/2011
Substance Manufacturer Name Sanofi PasteurGlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

Vaccine Administration Information - 24
Element Data
Administered Code Influenza, injectable,quadrivalent, preservative free, pediatric
Date/Time Start of Administration 10/27/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number D8043IN8734
Substance Expiration Date 03/12/2011
Substance Manufacturer Name Sanofi PasteurGlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Right Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

Vaccine Administration Information - 25
Element Data
Administered Code Influenza, injectable,quadrivalent, preservative free, pediatric
Date/Time Start of Administration 10/02/2011
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number D9334IN9333
Substance Expiration Date 05/22/2012
Substance Manufacturer Name Sanofi PasteurGlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

Vaccine Administration Information - 26
Element Data
Administered Code Influenza, injectable,quadrivalent, preservative free, pediatric
Date/Time Start of Administration 10/15/2013
Administered Amount 999
Administered Units
Administration Notes Historical information - from parents written record
Administering Provider Gina Ricci
Substance Lot Number 8L4B3423
Substance Expiration Date 07/01/2014
Substance Manufacturer Name MedImmune, LLC
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route Nasal
Administration Site Bilateral Nares
Entering Organization Shoreline Pediatrics
Entered By Sandra Molina
Ordered By Gina Ricci

Vaccine Administration Information - 27
Element Data
Administered Code influenza, live, intranasal, quadrivalent
Date/Time Start of Administration 07/15/2015
Administered Amount 0.2
Administered Units
Administration Notes New immunization record
Administering Provider Sandra Molina
Substance Lot Number 8L4B3521
Substance Expiration Date 08/15/2015
Substance Manufacturer Name MedImmune,LLC
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route Nasal
Administration Site Bilateral Nares
Entering Organization Shoreline Pediatrics
Entered By Sandra Molina
Ordered By Frank Smith

Observations
Element Data
VIS Publication Date 08/19/2014
VIS Presentation Date 07/15/2015
vaccine fund pgm elig cat Not VFC elig

Vaccine Administration Information - 28
Element Data
Administered Code influenza, live, intranasal, quadrivalent
Date/Time Start of Administration 11/04/2012
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number D9553IN2243
Substance Expiration Date 04/30/2012
Substance Manufacturer Name Sanofi PasteurGlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

Vaccine Administration Information - 29
Element Data
Administered Code hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
Date/Time Start of Administration 11/23/2011
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number 6359RT33
Substance Expiration Date 01/24/2012
Substance Manufacturer Name GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Right Deltoid
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

Vaccine Administration Information - 30
Element Data
Administered Code hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
Date/Time Start of Administration 05/23/2012
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number 6359RT48
Substance Expiration Date 09/11/2012
Substance Manufacturer Name Sanofi PasteurGlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By F Smith

Vaccine Administration Information - 31
Element Data
Administered Code measles, mumps, rubella, and varicella virus vaccine
Date/Time Start of Administration 10/23/2010
Administered Amount 999
Administered Units
Administration Notes historical
Administering Provider J Martinez
Substance Lot Number 7W27V7491
Substance Expiration Date 12/15/2010
Substance Manufacturer Name Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route Subcutaneous
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By F Smith

Vaccine Administration Information - 32
Element Data
Administered Code measles, mumps, rubella, and varicella virus vaccine
Date/Time Start of Administration 11/22/2012
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number 7W87V3452
Substance Expiration Date 04/13/2013
Substance Manufacturer Name Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route Subcutaneous
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By F Smith

Vaccine Administration Information - 33
Element Data
Administered Code measles, mumps, rubella, and varicella virus vaccine
Date/Time Start of Administration 07/15/2015
Administered Amount 0.5
Administered Units
Administration Notes New immunization record
Administering Provider Sandra Molina
Substance Lot Number 7W87V3687
Substance Expiration Date 07/15/2015
Substance Manufacturer Name Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route Subcutaneous
Administration Site Left Deltoid
Entering Organization Shoreline Pediatrics
Entered By Sandra Molina
Ordered By Frank Smith

Observations
Element Data
VIS Publication Date 05/21/2010
VIS Presentation Date 07/15/2015
vaccine fund pgm elig cat Not VFC elig
vaccine fund pgm elig cat Not VFC elig
Reaction persistent, inconsolable crying lasting > 3 hours within 48 hours of dose
Element Data
Patient Name Juana Mariana Gonzales
Mother's Maiden Name Maria Acosta
ID Number 123456 987633
Date/Time of Birth 12/23/2009
Administrative Sex Female
Patient Address 4345 Standish Way Stamford CT 06903 USA
Patient Address 1 325 Shorline Drive Stamford CT 06901
Local Number (203)555-1212
Race Other Race
Ethnic Group Hispanic or Latino
Birth Order
Element Data
Immunization Registry Status A
Immunization Registry Status Effective Date 07/01/2012
Publicity Code Reminder/Recall - any method
Publicity Code Effective Date 07/01/2012
Protection Indicator
Protection Indicator Effective Date
Element Data
Name Joanna Merida Gonzales
Relationship Grandparent
Address 4345 Standish Way Stamford CT 06901
Phone Number (203)555-1212
Vaccine Administration Information - 1
Element Data
Administered Code hepatitis B vaccine, pediatric or pediatric/adolescent dosage
Date/Time Start of Administration 11/23/2009
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider Lisa Sirtis
Substance Lot Number 6332FK33
Substance Expiration Date 12/14/2010
Substance Manufacturer Name GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Thigh
Entering Organization Shoreline Hospital
Entered By Lisa Sirtis
Ordered By Jane Carter

 Vaccine Administration Information - 2
Element Data
Administered Code hepatitis B vaccine, unspecified formulation
Date/Time Start of Administration 01/15/2010
Administered Amount 999
Administered Units
Administration Notes Historical Immunization
Administering Provider Sandra Molina
Substance Lot Number 6352FK1
Substance Expiration Date 10/01/2010
Substance Manufacturer Name GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Right Thigh
Entering Organization Shoreline Pediatrics
Entered By Sandra Molina
Ordered By Frank Smith

 Vaccine Administration Information - 3
Element Data
Administered Code hepatitis B vaccine, pediatric or pediatric/adolescent dosage
Date/Time Start of Administration 10/30/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number 6352FK24
Substance Expiration Date 08/31/2012
Substance Manufacturer Name GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

 Vaccine Administration Information - 4
Element Data
Administered Code diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Date/Time Start of Administration 01/22/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number D409QS2341
Substance Expiration Date 11/30/2011
Substance Manufacturer Name Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

 Vaccine Administration Information - 5
Element Data
Administered Code diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Date/Time Start of Administration 03/23/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number D409QS2433
Substance Expiration Date 09/04/2011
Substance Manufacturer Name Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Right Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

 Vaccine Administration Information - 6
Element Data
Administered Code diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Date/Time Start of Administration 05/22/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number D409QS3255
Substance Expiration Date 12/01/2010
Substance Manufacturer Name Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

Historical information - from public agency
Element Data
Reaction fever of >40.5C (105F) within 48 hours of dose

 Vaccine Administration Information - 7
Element Data
Administered Code diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Date/Time Start of Administration 02/21/2011
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number D409QS249
Substance Expiration Date 03/01/2011
Substance Manufacturer Name Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

 Vaccine Administration Information - 8
Element Data
Administered Code diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis
Date/Time Start of Administration 08/31/2014
Administered Amount 999
Administered Units
Administration Notes Historical information - from other provider
Administering Provider Linda Casera
Substance Lot Number D643QS8243
Substance Expiration Date 09/01/2014
Substance Manufacturer Name Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Deltoid
Entering Organization Shoreline Pediatrics
Entered By Sandra Molina
Ordered By J Rodriguez

 Vaccine Administration Information - 9
Element Data
Administered Code Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Date/Time Start of Administration 01/22/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number 7M54K9245
Substance Expiration Date 03/24/2010
Substance Manufacturer Name Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Right Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

 Vaccine Administration Information - 10
Element Data
Administered Code Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Date/Time Start of Administration 03/23/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number 7M55K3342
Substance Expiration Date 10/30/2010
Substance Manufacturer Name Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

 Vaccine Administration Information - 11
Element Data
Administered Code Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Date/Time Start of Administration 05/22/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number 7M75K4566
Substance Expiration Date 05/23/2010
Substance Manufacturer Name Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Right Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

 Vaccine Administration Information - 12
Element Data
Administered Code Haemophilus influenzae type b vaccine, PRP-OMP conjugate
Date/Time Start of Administration 02/21/2011
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number 7M53K5534
Substance Expiration Date 02/22/2011
Substance Manufacturer Name Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

 Vaccine Administration Information - 13
Element Data
Administered Code poliovirus vaccine, inactivated
Date/Time Start of Administration 01/22/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number D333PV2431
Substance Expiration Date 10/04/2010
Substance Manufacturer Name Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route SC
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

 Vaccine Administration Information - 14
Element Data
Administered Code poliovirus vaccine, inactivated
Date/Time Start of Administration 03/23/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number D333PV4344
Substance Expiration Date 03/23/2010
Substance Manufacturer Name Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route SC
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

 Vaccine Administration Information - 15
Element Data
Administered Code poliovirus vaccine, inactivated
Date/Time Start of Administration 02/21/2011
Administered Amount 999
Administered Units
Administration Notes Historical information - from other provider
Administering Provider Linda Casera
Substance Lot Number D335PV9644
Substance Expiration Date 02/22/2011
Substance Manufacturer Name Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route SC
Administration Site Left Deltoid
Entering Organization Shoreline Pediatrics
Entered By Sandra Molina
Ordered By J Rodriguez

 Vaccine Administration Information - 16
Element Data
Administered Code poliovirus vaccine, inactivated
Date/Time Start of Administration 05/19/2015
Administered Amount 999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason Parental decision
Completion Status RE
Action Code Add
Route
Administration Site
Entering Organization Shoreline Pediatrics
Entered By Sandra Molina
Ordered By Frank Smith

 Vaccine Administration Information - 17
Element Data
Administered Code pneumococcal conjugate vaccine, 13 valent
Date/Time Start of Administration 01/21/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number P243V3281
Substance Expiration Date 01/30/2010
Substance Manufacturer Name Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

 Vaccine Administration Information - 18
Element Data
Administered Code pneumococcal conjugate vaccine, 13 valent
Date/Time Start of Administration 03/23/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number P343V8321
Substance Expiration Date 03/30/2010
Substance Manufacturer Name Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route SC
Administration Site Left Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

 Vaccine Administration Information - 19
Element Data
Administered Code pneumococcal conjugate vaccine, 13 valent
Date/Time Start of Administration 05/22/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number P853V2164
Substance Expiration Date 08/30/2010
Substance Manufacturer Name Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Right Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

 Vaccine Administration Information - 20
Element Data
Administered Code pneumococcal conjugate vaccine, 13 valent
Date/Time Start of Administration 02/21/2011
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number P853V58532
Substance Expiration Date 04/18/2011
Substance Manufacturer Name Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

 Vaccine Administration Information - 21
Element Data
Administered Code rotavirus, live, monovalent vaccine
Date/Time Start of Administration 01/22/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number 6359RV533
Substance Expiration Date 02/15/2010
Substance Manufacturer Name GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

 Vaccine Administration Information - 22
Element Data
Administered Code rotavirus, live, monovalent vaccine
Date/Time Start of Administration 03/23/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number 6359RV932
Substance Expiration Date 05/10/2010
Substance Manufacturer Name GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Right Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

 Vaccine Administration Information - 23
Element Data
Administered Code Influenza, injectable,quadrivalent, preservative free, pediatric
Date/Time Start of Administration 09/25/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number D8043IN8734
Substance Expiration Date 03/12/2011
Substance Manufacturer Name Sanofi PasteurGlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

 Vaccine Administration Information - 24
Element Data
Administered Code Influenza, injectable,quadrivalent, preservative free, pediatric
Date/Time Start of Administration 10/27/2010
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number D8043IN8734
Substance Expiration Date 03/12/2011
Substance Manufacturer Name Sanofi PasteurGlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Right Thigh
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

 Vaccine Administration Information - 25
Element Data
Administered Code Influenza, injectable,quadrivalent, preservative free, pediatric
Date/Time Start of Administration 10/02/2011
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number D9334IN9333
Substance Expiration Date 05/22/2012
Substance Manufacturer Name Sanofi PasteurGlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

 Vaccine Administration Information - 26
Element Data
Administered Code Influenza, injectable,quadrivalent, preservative free, pediatric
Date/Time Start of Administration 10/15/2013
Administered Amount 999
Administered Units
Administration Notes Historical information - from parents written record
Administering Provider Gina Ricci
Substance Lot Number 8L4B3423
Substance Expiration Date 07/01/2014
Substance Manufacturer Name MedImmune, LLC
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route Nasal
Administration Site Bilateral Nares
Entering Organization Shoreline Pediatrics
Entered By Sandra Molina
Ordered By Gina Ricci

 Vaccine Administration Information - 27
Element Data
Administered Code influenza, live, intranasal, quadrivalent
Date/Time Start of Administration 07/15/2015
Administered Amount 0.2
Administered Units
Administration Notes New immunization record
Administering Provider Sandra Molina
Substance Lot Number 8L4B3521
Substance Expiration Date 08/15/2015
Substance Manufacturer Name MedImmune,LLC
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route Nasal
Administration Site Bilateral Nares
Entering Organization Shoreline Pediatrics
Entered By Sandra Molina
Ordered By Frank Smith

Observations
Element Data
VIS Publication Date 08/19/2014
VIS Presentation Date 07/15/2015
vaccine fund pgm elig cat Not VFC elig

 Vaccine Administration Information - 28
Element Data
Administered Code influenza, live, intranasal, quadrivalent
Date/Time Start of Administration 11/04/2012
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number D9553IN2243
Substance Expiration Date 04/30/2012
Substance Manufacturer Name Sanofi PasteurGlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

 Vaccine Administration Information - 29
Element Data
Administered Code hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
Date/Time Start of Administration 11/23/2011
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number 6359RT33
Substance Expiration Date 01/24/2012
Substance Manufacturer Name GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Right Deltoid
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By Carlos Herrera

 Vaccine Administration Information - 30
Element Data
Administered Code hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule
Date/Time Start of Administration 05/23/2012
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number 6359RT48
Substance Expiration Date 09/11/2012
Substance Manufacturer Name Sanofi PasteurGlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By F Smith

 Vaccine Administration Information - 31
Element Data
Administered Code measles, mumps, rubella, and varicella virus vaccine
Date/Time Start of Administration 10/23/2010
Administered Amount 999
Administered Units
Administration Notes historical
Administering Provider J Martinez
Substance Lot Number 7W27V7491
Substance Expiration Date 12/15/2010
Substance Manufacturer Name Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route Subcutaneous
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By F Smith

 Vaccine Administration Information - 32
Element Data
Administered Code measles, mumps, rubella, and varicella virus vaccine
Date/Time Start of Administration 11/22/2012
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider J Martinez
Substance Lot Number 7W87V3452
Substance Expiration Date 04/13/2013
Substance Manufacturer Name Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route Subcutaneous
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J Martinez
Ordered By F Smith

 Vaccine Administration Information - 33
Element Data
Administered Code measles, mumps, rubella, and varicella virus vaccine
Date/Time Start of Administration 07/15/2015
Administered Amount 0.5
Administered Units
Administration Notes New immunization record
Administering Provider Sandra Molina
Substance Lot Number 7W87V3687
Substance Expiration Date 07/15/2015
Substance Manufacturer Name Merck Sharp \T\ Dohme Corp
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route Subcutaneous
Administration Site Left Deltoid
Entering Organization Shoreline Pediatrics
Entered By Sandra Molina
Ordered By Frank Smith

Observations
Element Data
VIS Publication Date 05/21/2010
VIS Presentation Date 07/15/2015
vaccine fund pgm elig cat Not VFC elig
vaccine fund pgm elig cat Not VFC elig
Reaction persistent, inconsolable crying lasting > 3 hours within 48 hours of dose

4.2. Juan Marcel Gonzales Transmit Immunization Report

Send the Immunization Report to the Immunization Registry (VXU/Z22) for Juan Marcel Gonzales.

Test Story

Description
No Description

Comments
No Comments

PreCondition
No PreCondition

PostCondition
No PostCondition

Test Objectives
No Test Objectives

Evaluation Criteria
No evaluation criteria

Notes to Testers
No Note

4.2.1. Transmit the Immunization Report for Juan Marcel Gonzales

Test Step Type: SUT_INITIATOR
The EMR sends the Immunization Report to the Immunization Registry (VXU/Z22) for updated vaccination information from the visit. This includes all newly administered vaccines and may include historical information updated in the EMR during the visit.

Test Story

Description

Following the vaccinations given during the visit, the EMR transmits an Immunization report to the Immunization Registry using the VXU/Z22. The Vaccination report includes all newly administered vaccines. The report MAY send the immunizations that the EMR imported from the IIS.

Comments

The Report must include all newly administered vaccines in any order. The report may include the information imported from the IIS.

PreCondition

The vaccines for the visit have been administered.

PostCondition

The Immunization Report has been transmitted to the IIS using a valid Z22 VXU in accordance with the test data correctly and without omission.

Test Objectives

Transmit Standard Patient Immunization History Report: The EHR or other clinical software system directly or indirectly through an intermediary creates and transmits a report of a patient's immunization history to public health immunization registries.
The VXU/Z22 message passes validation using the NIST Immunization VXU Validation Tool (Z22) (context-free). The content of the message correctly reflects the test data (context-based) in accordance with the Test Data Specification and the Message Content.

Evaluation Criteria

The VXU/Z22 message passes validation using the NIST Immunization VXU Validation Tool (Z22) (context-free). The content of the message correctly reflects the test data (context-based) in accordance with the Test Data Specification and the Message Content.

Notes to Testers

No Note

Message Contents

MSH
Location Data Element Data Categorization
MSH.1 Field Separator |
MSH.2 Encoding Characters ^~\&
MSH.3 Sending Application
MSH.3.1 Namespace ID Test EHR Application
MSH.3.2 Universal ID
MSH.3.3 Universal ID Type
MSH.4 Sending Facility
MSH.4.1 Namespace ID X68
MSH.4.2 Universal ID
MSH.4.3 Universal ID Type
MSH.5 Receiving Application
MSH.5.1 Namespace ID
MSH.5.2 Universal ID
MSH.5.3 Universal ID Type
MSH.6 Receiving Facility
MSH.6.1 Namespace ID NIST Test Iz Reg
MSH.6.2 Universal ID
MSH.6.3 Universal ID Type
MSH.7 Date/Time Of Message
MSH.7.1 Time 20120701082240-0500
MSH.9 Message Type
MSH.9.1 Message Code VXU
MSH.9.2 Trigger Event V04
MSH.9.3 Message Structure VXU_V04
MSH.10 Message Control ID NIST-IZ-001.00
MSH.11 Processing ID
MSH.11.1 Processing ID P
MSH.12 Version ID
MSH.12.1 Version ID 2.5.1
MSH.15 Accept Acknowledgment Type ER
MSH.16 Application Acknowledgment Type AL
MSH.21 Message Profile Identifier
MSH.21.1 Entity Identifier Z22
MSH.21.2 Namespace ID CDCPHINVS
MSH.21.3 Universal ID
MSH.21.4 Universal ID Type
MSH.22 Sending Responsible Organization
MSH.22.1 Organization Name
MSH.22.6 Assigning Authority
MSH.22.6.1 Namespace ID
MSH.22.6.2 Universal ID
MSH.22.6.3 Universal ID Type
MSH.22.7 Identifier Type Code
MSH.22.10 Organization Identifier
MSH.23 Receiving Responsible Organization
MSH.23.1 Organization Name
MSH.23.6 Assigning Authority
MSH.23.6.1 Namespace ID
MSH.23.6.2 Universal ID
MSH.23.6.3 Universal ID Type
MSH.23.7 Identifier Type Code
MSH.23.10 Organization Identifier

PID
Location Data Element Data Categorization
PID.1 Set ID - PID 1
PID.3 Patient Identifier List
PID.3.1 ID Number 123456
PID.3.3 Check Digit Scheme
PID.3.4 Assigning Authority
PID.3.4.1 Namespace ID MYEHR
PID.3.4.2 Universal ID
PID.3.4.3 Universal ID Type
PID.3.5 Identifier Type Code MR
PID.3 Patient Identifier List
PID.3.1 ID Number 987633
PID.3.3 Check Digit Scheme
PID.3.4 Assigning Authority
PID.3.4.1 Namespace ID MYIIS
PID.3.4.2 Universal ID
PID.3.4.3 Universal ID Type
PID.3.5 Identifier Type Code SR
PID.5 Patient Name
PID.5.1 Family Name
PID.5.1.1 Surname Gonzales
PID.5.1.2 Own Surname Prefix
PID.5.1.3 Own Surname
PID.5.1.4 Surname Prefix From Partner/Spouse
PID.5.1.5 Surname From Partner/Spouse
PID.5.2 Given Name Juan Test Case Fixed
PID.5.3 Second and Further Given Names or Initials Thereof Marcel Test Case Fixed
PID.5.7 Name Type Code L Test Case Fixed
PID.6 Mother's Maiden Name
PID.6.1 Family Name
PID.6.1.1 Surname Morales Test Case Fixed
PID.6.1.2 Own Surname Prefix
PID.6.1.3 Own Surname
PID.6.1.4 Surname Prefix From Partner/Spouse
PID.6.1.5 Surname From Partner/Spouse
PID.6.7 Name Type Code M Test Case Fixed
PID.7 Date/Time of Birth
PID.7.1 Time 201111231100 Test Case Fixed
PID.8 Administrative Sex M Test Case Fixed
PID.10 Race
PID.10.1 Identifier 2131-1 Test Case Fixed
PID.10.2 Text Other Race Test Case Fixed
PID.10.3 Name of Coding System HL70005 Test Case Fixed
PID.10.5 Alternate Text
PID.10.6 Name of Alternate Coding System
PID.11 Patient Address
PID.11.1 Street Address
PID.11.1.1 Street or Mailing Address 4623 Standish Way Test Case Fixed
PID.11.1.2 Street Name
PID.11.1.3 Dwelling Number
PID.11.2 Other Designation
PID.11.3 City Stamford Test Case Fixed
PID.11.4 State or Province CT Test Case Fixed
PID.11.5 Zip or Postal Code 06903 Test Case Fixed
PID.11.6 Country USA Test Case Fixed
PID.11.7 Address Type L Test Case Fixed
PID.13 Phone Number - Home
PID.13.2 Telecommunication Use Code PRN Test Case Fixed
PID.13.3 Telecommunication Equipment Type PH Test Case Fixed
PID.13.4 Email Address
PID.13.6 Area/City Code 203 Test Case Fixed
PID.13.7 Local Number 5551213 Test Case Fixed
PID.22 Ethnic Group
PID.22.1 Identifier 2135-2 Test Case Fixed
PID.22.2 Text Hispanic or Latino Test Case Fixed
PID.22.3 Name of Coding System CDCREC Test Case Fixed
PID.22.5 Alternate Text
PID.22.6 Name of Alternate Coding System
PID.24 Multiple Birth Indicator
PID.25 Birth Order
PID.29 Patient Death Date and Time
PID.29.1 Time
PID.30 Patient Death Indicator

PD1
Location Data Element Data Categorization
PD1.11 Publicity Code
PD1.11.1 Identifier 02
PD1.11.2 Text Reminder/Recall - any method
PD1.11.3 Name of Coding System HL70215
PD1.11.5 Alternate Text
PD1.11.6 Name of Alternate Coding System
PD1.12 Protection Indicator
PD1.13 Protection Indicator Effective Date
PD1.16 Immunization Registry Status A
PD1.17 Immunization Registry Status Effective Date 20120701
PD1.18 Publicity Code Effective Date 20120701

NK1
Location Data Element Data Categorization
NK1.1 Set ID - NK1 1
NK1.2 Name
NK1.2.1 Family Name
NK1.2.1.1 Surname Gonzales Test Case Fixed
NK1.2.1.2 Own Surname Prefix
NK1.2.1.3 Own Surname
NK1.2.1.4 Surname Prefix From Partner/Spouse
NK1.2.1.5 Surname From Partner/Spouse
NK1.2.2 Given Name Manuel Test Case Fixed
NK1.2.3 Second and Further Given Names or Initials Thereof Marcel Test Case Fixed
NK1.2.7 Name Type Code L Test Case Fixed
NK1.3 Relationship
NK1.3.1 Identifier FTH Test Case Fixed
NK1.3.2 Text Father Test Case Fixed
NK1.3.3 Name of Coding System HL70063 Test Case Fixed
NK1.3.5 Alternate Text
NK1.3.6 Name of Alternate Coding System
NK1.4 Address
NK1.4.1 Street Address
NK1.4.1.1 Street or Mailing Address 4623 Standish Way Test Case Fixed
NK1.4.1.2 Street Name
NK1.4.1.3 Dwelling Number
NK1.4.2 Other Designation
NK1.4.3 City Stamford Test Case Fixed
NK1.4.4 State or Province CT Test Case Fixed
NK1.4.5 Zip or Postal Code 06903 Test Case Fixed
NK1.4.6 Country
NK1.4.7 Address Type L
NK1.5 Phone Number
NK1.5.2 Telecommunication Use Code PRN Test Case Fixed
NK1.5.3 Telecommunication Equipment Type PH Test Case Fixed
NK1.5.4 Email Address
NK1.5.6 Area/City Code 203 Test Case Fixed
NK1.5.7 Local Number 5551213 Test Case Fixed

ORC[*]
ORC - 1
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Sirtis
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name Lisa
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Carter
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Jane
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier SH
ORC.17.2 Text Shoreline Hospital
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 2
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J.
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J.
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 3
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Molina
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name Sandra
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Smith
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Frank
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier SP
ORC.17.2 Text Shoreline Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 4
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J.
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J.
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 5
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J.
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J.
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 6
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J.
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J.
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 7
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J.
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J.
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 8
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J.
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J.
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 9
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J.
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J.
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 10
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J.
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J.
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 11
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J.
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J.
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 12
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J.
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J.
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 13
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J.
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J.
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 14
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J.
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J.
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 15
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J.
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J.
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 16
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J.
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J.
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 17
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J.
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J.
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 18
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J.
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J.
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 19
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J.
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J.
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 20
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J.
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J.
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 21
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J.
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J.
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 22
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J.
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J.
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 23
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J.
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J.
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 24
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Molina
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name Sandra
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Smith
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Frank
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier SP
ORC.17.2 Text Shoreline Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 25
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J.
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J.
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 26
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J.
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J.
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 27
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J.
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J.
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

RXA[*]
RXA - 1
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20111123
RXA.5 Administered Code
RXA.5.1 Identifier 08
RXA.5.2 Text Hepatitis B
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text ENGERIX-B
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J.
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 6332FK34
RXA.16 Substance Expiration Date
RXA.16.1 Time 20111214
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier SKB
RXA.17.2 Text GlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 2
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20111223
RXA.5 Administered Code
RXA.5.1 Identifier 08
RXA.5.2 Text Hepatitis B
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text ENGERIX-B
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J.
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 6352FK2
RXA.16 Substance Expiration Date
RXA.16.1 Time 20111001
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier SKB
RXA.17.2 Text GlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 3
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20150715
RXA.5 Administered Code
RXA.5.1 Identifier 08
RXA.5.2 Text Hepatitis B
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text ENGERIX-B
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 0.5
RXA.7 Administered Units
RXA.7.1 Identifier mL
RXA.7.2 Text
RXA.7.3 Name of Coding System UCUM
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 00
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Molina
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name Sandra
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 6332FK26
RXA.16 Substance Expiration Date
RXA.16.1 Time 20150825
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier SKB
RXA.17.2 Text GlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 4
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20120122
RXA.5 Administered Code
RXA.5.1 Identifier 106
RXA.5.2 Text DTaP
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text DAPTACEL
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J.
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D409QS2342
RXA.16 Substance Expiration Date
RXA.16.1 Time 20121130
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi Pasteur Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 5
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20120322
RXA.5 Administered Code
RXA.5.1 Identifier 106
RXA.5.2 Text DTaP
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text DAPTACEL
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J.
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D409QS2434
RXA.16 Substance Expiration Date
RXA.16.1 Time 20120904
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi Pasteur Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 6
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20120521
RXA.5 Administered Code
RXA.5.1 Identifier 106
RXA.5.2 Text DTaP
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text DAPTACEL
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J.
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D409QS250
RXA.16 Substance Expiration Date
RXA.16.1 Time 20140103
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi Pasteur Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 7
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20130220
RXA.5 Administered Code
RXA.5.1 Identifier 106
RXA.5.2 Text DTaP
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text DAPTACEL
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J.
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D409QS250
RXA.16 Substance Expiration Date
RXA.16.1 Time 20140103
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi Pasteur Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 8
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20120122
RXA.5 Administered Code
RXA.5.1 Identifier 49
RXA.5.2 Text Hib
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text PedvaxHIB
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J.
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 7M54K9255
RXA.16 Substance Expiration Date
RXA.16.1 Time 20120324
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier MSD
RXA.17.2 Text Merck Sharp and Dohme Corp.
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 9
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20120322
RXA.5 Administered Code
RXA.5.1 Identifier 49
RXA.5.2 Text Hib
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text PedvaxHIB
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J.
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 7M55K3343
RXA.16 Substance Expiration Date
RXA.16.1 Time 20121030
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier MSD
RXA.17.2 Text Merck Sharp and Dohme Corp.
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 10
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20120512
RXA.5 Administered Code
RXA.5.1 Identifier 49
RXA.5.2 Text Hib
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text PedvaxHIB
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J.
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 7M75K4577
RXA.16 Substance Expiration Date
RXA.16.1 Time 20120523
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier MSD
RXA.17.2 Text Merck Sharp and Dohme Corp.
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 11
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20120222
RXA.5 Administered Code
RXA.5.1 Identifier 49
RXA.5.2 Text Hib
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text PedvaxHIB
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J.
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 7M53K5535
RXA.16 Substance Expiration Date
RXA.16.1 Time 20120222
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier MSD
RXA.17.2 Text Merck Sharp and Dohme Corp.
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 12
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20120122
RXA.5 Administered Code
RXA.5.1 Identifier 10
RXA.5.2 Text Polio (IPV)
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text IPOL
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J.
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D333PV2444
RXA.16 Substance Expiration Date
RXA.16.1 Time 20120410
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text MSanofi Pasteur Inc.
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 13
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20120322
RXA.5 Administered Code
RXA.5.1 Identifier 10
RXA.5.2 Text Polio (IPV)
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text IPOL
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J.
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D333PV4343
RXA.16 Substance Expiration Date
RXA.16.1 Time 20120323
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text MSanofi Pasteur Inc.
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 14
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20120521
RXA.5 Administered Code
RXA.5.1 Identifier 10
RXA.5.2 Text Polio (IPV)
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text IPOL
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J.
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D333PV4343
RXA.16 Substance Expiration Date
RXA.16.1 Time 20120323
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text MSanofi Pasteur Inc.
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 15
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20120122
RXA.5 Administered Code
RXA.5.1 Identifier 133
RXA.5.2 Text Pneumococcal conjugate (PCV13)
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text PREVNAR 13
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J.
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number P243V3321
RXA.16 Substance Expiration Date
RXA.16.1 Time 20120130
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PFR
RXA.17.2 Text Pfizer, Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 16
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20120322
RXA.5 Administered Code
RXA.5.1 Identifier 133
RXA.5.2 Text Pneumococcal conjugate (PCV13)
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text PREVNAR 13
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J.
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number P343V8445
RXA.16 Substance Expiration Date
RXA.16.1 Time 20120330
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PFR
RXA.17.2 Text Pfizer, Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 17
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20120521
RXA.5 Administered Code
RXA.5.1 Identifier 133
RXA.5.2 Text Pneumococcal conjugate (PCV13)
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text PREVNAR 13
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J.
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number P853V2175
RXA.16 Substance Expiration Date
RXA.16.1 Time 20120830
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PFR
RXA.17.2 Text Pfizer, Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 18
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20121122
RXA.5 Administered Code
RXA.5.1 Identifier 133
RXA.5.2 Text Pneumococcal conjugate (PCV13)
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text PREVNAR 13
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J.
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number P853V58544
RXA.16 Substance Expiration Date
RXA.16.1 Time 20130118
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PFR
RXA.17.2 Text Pfizer, Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 19
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20121122
RXA.5 Administered Code
RXA.5.1 Identifier 119
RXA.5.2 Text Rotavirus
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text ROTARIX
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J.
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 6359RV543
RXA.16 Substance Expiration Date
RXA.16.1 Time 20120215
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier SKB
RXA.17.2 Text GlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 20
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20120322
RXA.5 Administered Code
RXA.5.1 Identifier 119
RXA.5.2 Text Rotavirus
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text ROTARIX
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J.
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 6359RV933
RXA.16 Substance Expiration Date
RXA.16.1 Time 20120510
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier SKB
RXA.17.2 Text GlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 21
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20120922
RXA.5 Administered Code
RXA.5.1 Identifier 161
RXA.5.2 Text Influenza
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text FLUZONE QUADRIVALENT
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J.
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D8043IN8738
RXA.16 Substance Expiration Date
RXA.16.1 Time 20130312
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi Pasteur
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 22
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20121022
RXA.5 Administered Code
RXA.5.1 Identifier 161
RXA.5.2 Text Influenza
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text FLUZONE QUADRIVALENT
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J.
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D8043IN8798
RXA.16 Substance Expiration Date
RXA.16.1 Time 20130312
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi Pasteur
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 23
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20131030
RXA.5 Administered Code
RXA.5.1 Identifier 161
RXA.5.2 Text Influenza
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text FLUZONE QUADRIVALENT
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J.
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D9334IN9433
RXA.16 Substance Expiration Date
RXA.16.1 Time 20140522
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi Pasteur
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 24
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20150715
RXA.5 Administered Code
RXA.5.1 Identifier 161
RXA.5.2 Text Influenza
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text FLUZONE QUADRIVALENT
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 0.25
RXA.7 Administered Units
RXA.7.1 Identifier mL
RXA.7.2 Text
RXA.7.3 Name of Coding System UCUM
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 00
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Molina
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name Sandra
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D8043IN8855
RXA.16 Substance Expiration Date
RXA.16.1 Time 20150828
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi Pasteur
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 25
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20130521
RXA.5 Administered Code
RXA.5.1 Identifier 83
RXA.5.2 Text Hepatitis A
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text HAVRIX
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J.
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 6359RT35
RXA.16 Substance Expiration Date
RXA.16.1 Time 20140104
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier SKB
RXA.17.2 Text GlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 26
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20131201
RXA.5 Administered Code
RXA.5.1 Identifier 83
RXA.5.2 Text Hepatitis A
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text HAVRIX
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J.
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 6359RT47
RXA.16 Substance Expiration Date
RXA.16.1 Time 20130911
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier SKB
RXA.17.2 Text GlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 27
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20130112
RXA.5 Administered Code
RXA.5.1 Identifier 94
RXA.5.2 Text MMR and Varicella
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text ProQuad
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J.
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 7W27V7632
RXA.16 Substance Expiration Date
RXA.16.1 Time 20161215
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier MSD
RXA.17.2 Text Merck Sharp and Dohme Corp.
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXR[*]
RXR - 1
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 2
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier RT
RXR.2.2 Text Right Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 3
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 4
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 5
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 6
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 7
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 8
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier RT
RXR.2.2 Text Right Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 9
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 10
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier RT
RXR.2.2 Text Right Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 11
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 12
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text SC
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text SC
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 13
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text SC
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text SC
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 14
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text SC
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text SC
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 15
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 16
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 17
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier RT
RXR.2.2 Text Right Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 18
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 19
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 20
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier RT
RXR.2.2 Text Thigh Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 21
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 22
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier RT
RXR.2.2 Text Right Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 23
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 24
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 25
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier RD
RXR.2.2 Text Right Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 26
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 27
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text SC
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text SC
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

OBX[*]
OBX - 1
Location Data Element Data Categorization
OBX.1 Set ID - OBX 2
OBX.2 Value Type TS
OBX.3 Observation Identifier
OBX.3.1 Identifier 29768-9
OBX.3.2 Text VIS Publication Date
OBX.3.3 Name of Coding System LN
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.5.1 Time 20120202
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 2
Location Data Element Data Categorization
OBX.1 Set ID - OBX 3
OBX.2 Value Type TS
OBX.3 Observation Identifier
OBX.3.1 Identifier 29769-7
OBX.3.2 Text VIS Presentation Date
OBX.3.3 Name of Coding System LN
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.5.1 Time 20150715
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 3
Location Data Element Data Categorization
OBX.1 Set ID - OBX 1
OBX.2 Value Type CE
OBX.3 Observation Identifier
OBX.3.1 Identifier 64994-7
OBX.3.2 Text vaccine fund pgm elig cat
OBX.3.3 Name of Coding System LN
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 4
Location Data Element Data Categorization
OBX.1 Set ID - OBX 2
OBX.2 Value Type TS
OBX.3 Observation Identifier
OBX.3.1 Identifier 29768-9
OBX.3.2 Text VIS Publication Date
OBX.3.3 Name of Coding System LN
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.5.1 Time 20140819
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 5
Location Data Element Data Categorization
OBX.1 Set ID - OBX 3
OBX.2 Value Type TS
OBX.3 Observation Identifier
OBX.3.1 Identifier 29769-7
OBX.3.2 Text VIS Presentation Date
OBX.3.3 Name of Coding System LN
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.5.1 Time 20150715
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 6
Location Data Element Data Categorization
OBX.1 Set ID - OBX 1
OBX.2 Value Type CE
OBX.3 Observation Identifier
OBX.3.1 Identifier 64994-7
OBX.3.2 Text vaccine fund pgm elig cat
OBX.3.3 Name of Coding System LN
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

Location Data Element Data Categorization
MSH.1 Field Separator |
MSH.2 Encoding Characters ^~\&
MSH.3 Sending Application
MSH.3.1 Namespace ID Test EHR Application
MSH.3.2 Universal ID
MSH.3.3 Universal ID Type
MSH.4 Sending Facility
MSH.4.1 Namespace ID X68
MSH.4.2 Universal ID
MSH.4.3 Universal ID Type
MSH.5 Receiving Application
MSH.5.1 Namespace ID
MSH.5.2 Universal ID
MSH.5.3 Universal ID Type
MSH.6 Receiving Facility
MSH.6.1 Namespace ID NIST Test Iz Reg
MSH.6.2 Universal ID
MSH.6.3 Universal ID Type
MSH.7 Date/Time Of Message
MSH.7.1 Time 20120701082240-0500
MSH.9 Message Type
MSH.9.1 Message Code VXU
MSH.9.2 Trigger Event V04
MSH.9.3 Message Structure VXU_V04
MSH.10 Message Control ID NIST-IZ-001.00
MSH.11 Processing ID
MSH.11.1 Processing ID P
MSH.12 Version ID
MSH.12.1 Version ID 2.5.1
MSH.15 Accept Acknowledgment Type ER
MSH.16 Application Acknowledgment Type AL
MSH.21 Message Profile Identifier
MSH.21.1 Entity Identifier Z22
MSH.21.2 Namespace ID CDCPHINVS
MSH.21.3 Universal ID
MSH.21.4 Universal ID Type
MSH.22 Sending Responsible Organization
MSH.22.1 Organization Name
MSH.22.6 Assigning Authority
MSH.22.6.1 Namespace ID
MSH.22.6.2 Universal ID
MSH.22.6.3 Universal ID Type
MSH.22.7 Identifier Type Code
MSH.22.10 Organization Identifier
MSH.23 Receiving Responsible Organization
MSH.23.1 Organization Name
MSH.23.6 Assigning Authority
MSH.23.6.1 Namespace ID
MSH.23.6.2 Universal ID
MSH.23.6.3 Universal ID Type
MSH.23.7 Identifier Type Code
MSH.23.10 Organization Identifier

Location Data Element Data Categorization
PID.1 Set ID - PID 1
PID.3 Patient Identifier List
PID.3.1 ID Number 123456
PID.3.3 Check Digit Scheme
PID.3.4 Assigning Authority
PID.3.4.1 Namespace ID MYEHR
PID.3.4.2 Universal ID
PID.3.4.3 Universal ID Type
PID.3.5 Identifier Type Code MR
PID.3 Patient Identifier List
PID.3.1 ID Number 987633
PID.3.3 Check Digit Scheme
PID.3.4 Assigning Authority
PID.3.4.1 Namespace ID MYIIS
PID.3.4.2 Universal ID
PID.3.4.3 Universal ID Type
PID.3.5 Identifier Type Code SR
PID.5 Patient Name
PID.5.1 Family Name
PID.5.1.1 Surname Gonzales
PID.5.1.2 Own Surname Prefix
PID.5.1.3 Own Surname
PID.5.1.4 Surname Prefix From Partner/Spouse
PID.5.1.5 Surname From Partner/Spouse
PID.5.2 Given Name Juan Test Case Fixed
PID.5.3 Second and Further Given Names or Initials Thereof Marcel Test Case Fixed
PID.5.7 Name Type Code L Test Case Fixed
PID.6 Mother's Maiden Name
PID.6.1 Family Name
PID.6.1.1 Surname Morales Test Case Fixed
PID.6.1.2 Own Surname Prefix
PID.6.1.3 Own Surname
PID.6.1.4 Surname Prefix From Partner/Spouse
PID.6.1.5 Surname From Partner/Spouse
PID.6.7 Name Type Code M Test Case Fixed
PID.7 Date/Time of Birth
PID.7.1 Time 201111231100 Test Case Fixed
PID.8 Administrative Sex M Test Case Fixed
PID.10 Race
PID.10.1 Identifier 2131-1 Test Case Fixed
PID.10.2 Text Other Race Test Case Fixed
PID.10.3 Name of Coding System HL70005 Test Case Fixed
PID.10.5 Alternate Text
PID.10.6 Name of Alternate Coding System
PID.11 Patient Address
PID.11.1 Street Address
PID.11.1.1 Street or Mailing Address 4623 Standish Way Test Case Fixed
PID.11.1.2 Street Name
PID.11.1.3 Dwelling Number
PID.11.2 Other Designation
PID.11.3 City Stamford Test Case Fixed
PID.11.4 State or Province CT Test Case Fixed
PID.11.5 Zip or Postal Code 06903 Test Case Fixed
PID.11.6 Country USA Test Case Fixed
PID.11.7 Address Type L Test Case Fixed
PID.13 Phone Number - Home
PID.13.2 Telecommunication Use Code PRN Test Case Fixed
PID.13.3 Telecommunication Equipment Type PH Test Case Fixed
PID.13.4 Email Address
PID.13.6 Area/City Code 203 Test Case Fixed
PID.13.7 Local Number 5551213 Test Case Fixed
PID.22 Ethnic Group
PID.22.1 Identifier 2135-2 Test Case Fixed
PID.22.2 Text Hispanic or Latino Test Case Fixed
PID.22.3 Name of Coding System CDCREC Test Case Fixed
PID.22.5 Alternate Text
PID.22.6 Name of Alternate Coding System
PID.24 Multiple Birth Indicator
PID.25 Birth Order
PID.29 Patient Death Date and Time
PID.29.1 Time
PID.30 Patient Death Indicator

Location Data Element Data Categorization
PD1.11 Publicity Code
PD1.11.1 Identifier 02
PD1.11.2 Text Reminder/Recall - any method
PD1.11.3 Name of Coding System HL70215
PD1.11.5 Alternate Text
PD1.11.6 Name of Alternate Coding System
PD1.12 Protection Indicator
PD1.13 Protection Indicator Effective Date
PD1.16 Immunization Registry Status A
PD1.17 Immunization Registry Status Effective Date 20120701
PD1.18 Publicity Code Effective Date 20120701

Location Data Element Data Categorization
NK1.1 Set ID - NK1 1
NK1.2 Name
NK1.2.1 Family Name
NK1.2.1.1 Surname Gonzales Test Case Fixed
NK1.2.1.2 Own Surname Prefix
NK1.2.1.3 Own Surname
NK1.2.1.4 Surname Prefix From Partner/Spouse
NK1.2.1.5 Surname From Partner/Spouse
NK1.2.2 Given Name Manuel Test Case Fixed
NK1.2.3 Second and Further Given Names or Initials Thereof Marcel Test Case Fixed
NK1.2.7 Name Type Code L Test Case Fixed
NK1.3 Relationship
NK1.3.1 Identifier FTH Test Case Fixed
NK1.3.2 Text Father Test Case Fixed
NK1.3.3 Name of Coding System HL70063 Test Case Fixed
NK1.3.5 Alternate Text
NK1.3.6 Name of Alternate Coding System
NK1.4 Address
NK1.4.1 Street Address
NK1.4.1.1 Street or Mailing Address 4623 Standish Way Test Case Fixed
NK1.4.1.2 Street Name
NK1.4.1.3 Dwelling Number
NK1.4.2 Other Designation
NK1.4.3 City Stamford Test Case Fixed
NK1.4.4 State or Province CT Test Case Fixed
NK1.4.5 Zip or Postal Code 06903 Test Case Fixed
NK1.4.6 Country
NK1.4.7 Address Type L
NK1.5 Phone Number
NK1.5.2 Telecommunication Use Code PRN Test Case Fixed
NK1.5.3 Telecommunication Equipment Type PH Test Case Fixed
NK1.5.4 Email Address
NK1.5.6 Area/City Code 203 Test Case Fixed
NK1.5.7 Local Number 5551213 Test Case Fixed

ORC - 1
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Sirtis
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name Lisa
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Carter
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Jane
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier SH
ORC.17.2 Text Shoreline Hospital
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 2
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J.
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J.
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 3
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Molina
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name Sandra
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Smith
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Frank
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier SP
ORC.17.2 Text Shoreline Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 4
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J.
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J.
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 5
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J.
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J.
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 6
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J.
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J.
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 7
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J.
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J.
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 8
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J.
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J.
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 9
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J.
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J.
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 10
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J.
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J.
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 11
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J.
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J.
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 12
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J.
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J.
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 13
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J.
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J.
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 14
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J.
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J.
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 15
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J.
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J.
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 16
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J.
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J.
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 17
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J.
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J.
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 18
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J.
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J.
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 19
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J.
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J.
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 20
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J.
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J.
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 21
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J.
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J.
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 22
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J.
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J.
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 23
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J.
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J.
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 24
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Molina
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name Sandra
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Smith
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Frank
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier SP
ORC.17.2 Text Shoreline Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 25
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J.
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J.
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 26
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J.
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J.
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 27
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Martinez
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name J.
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Rodriguez
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name J.
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier OP
ORC.17.2 Text Oceanview Pediatrics
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

RXA - 1
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20111123
RXA.5 Administered Code
RXA.5.1 Identifier 08
RXA.5.2 Text Hepatitis B
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text ENGERIX-B
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J.
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 6332FK34
RXA.16 Substance Expiration Date
RXA.16.1 Time 20111214
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier SKB
RXA.17.2 Text GlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 2
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20111223
RXA.5 Administered Code
RXA.5.1 Identifier 08
RXA.5.2 Text Hepatitis B
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text ENGERIX-B
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J.
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 6352FK2
RXA.16 Substance Expiration Date
RXA.16.1 Time 20111001
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier SKB
RXA.17.2 Text GlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 3
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20150715
RXA.5 Administered Code
RXA.5.1 Identifier 08
RXA.5.2 Text Hepatitis B
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text ENGERIX-B
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 0.5
RXA.7 Administered Units
RXA.7.1 Identifier mL
RXA.7.2 Text
RXA.7.3 Name of Coding System UCUM
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 00
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Molina
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name Sandra
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 6332FK26
RXA.16 Substance Expiration Date
RXA.16.1 Time 20150825
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier SKB
RXA.17.2 Text GlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 4
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20120122
RXA.5 Administered Code
RXA.5.1 Identifier 106
RXA.5.2 Text DTaP
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text DAPTACEL
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J.
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D409QS2342
RXA.16 Substance Expiration Date
RXA.16.1 Time 20121130
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi Pasteur Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 5
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20120322
RXA.5 Administered Code
RXA.5.1 Identifier 106
RXA.5.2 Text DTaP
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text DAPTACEL
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J.
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D409QS2434
RXA.16 Substance Expiration Date
RXA.16.1 Time 20120904
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi Pasteur Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 6
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20120521
RXA.5 Administered Code
RXA.5.1 Identifier 106
RXA.5.2 Text DTaP
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text DAPTACEL
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J.
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D409QS250
RXA.16 Substance Expiration Date
RXA.16.1 Time 20140103
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi Pasteur Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 7
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20130220
RXA.5 Administered Code
RXA.5.1 Identifier 106
RXA.5.2 Text DTaP
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text DAPTACEL
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J.
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D409QS250
RXA.16 Substance Expiration Date
RXA.16.1 Time 20140103
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi Pasteur Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 8
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20120122
RXA.5 Administered Code
RXA.5.1 Identifier 49
RXA.5.2 Text Hib
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text PedvaxHIB
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J.
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 7M54K9255
RXA.16 Substance Expiration Date
RXA.16.1 Time 20120324
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier MSD
RXA.17.2 Text Merck Sharp and Dohme Corp.
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 9
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20120322
RXA.5 Administered Code
RXA.5.1 Identifier 49
RXA.5.2 Text Hib
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text PedvaxHIB
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J.
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 7M55K3343
RXA.16 Substance Expiration Date
RXA.16.1 Time 20121030
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier MSD
RXA.17.2 Text Merck Sharp and Dohme Corp.
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 10
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20120512
RXA.5 Administered Code
RXA.5.1 Identifier 49
RXA.5.2 Text Hib
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text PedvaxHIB
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J.
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 7M75K4577
RXA.16 Substance Expiration Date
RXA.16.1 Time 20120523
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier MSD
RXA.17.2 Text Merck Sharp and Dohme Corp.
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 11
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20120222
RXA.5 Administered Code
RXA.5.1 Identifier 49
RXA.5.2 Text Hib
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text PedvaxHIB
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J.
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 7M53K5535
RXA.16 Substance Expiration Date
RXA.16.1 Time 20120222
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier MSD
RXA.17.2 Text Merck Sharp and Dohme Corp.
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 12
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20120122
RXA.5 Administered Code
RXA.5.1 Identifier 10
RXA.5.2 Text Polio (IPV)
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text IPOL
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J.
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D333PV2444
RXA.16 Substance Expiration Date
RXA.16.1 Time 20120410
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text MSanofi Pasteur Inc.
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 13
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20120322
RXA.5 Administered Code
RXA.5.1 Identifier 10
RXA.5.2 Text Polio (IPV)
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text IPOL
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J.
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D333PV4343
RXA.16 Substance Expiration Date
RXA.16.1 Time 20120323
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text MSanofi Pasteur Inc.
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 14
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20120521
RXA.5 Administered Code
RXA.5.1 Identifier 10
RXA.5.2 Text Polio (IPV)
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text IPOL
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J.
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D333PV4343
RXA.16 Substance Expiration Date
RXA.16.1 Time 20120323
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text MSanofi Pasteur Inc.
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 15
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20120122
RXA.5 Administered Code
RXA.5.1 Identifier 133
RXA.5.2 Text Pneumococcal conjugate (PCV13)
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text PREVNAR 13
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J.
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number P243V3321
RXA.16 Substance Expiration Date
RXA.16.1 Time 20120130
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PFR
RXA.17.2 Text Pfizer, Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 16
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20120322
RXA.5 Administered Code
RXA.5.1 Identifier 133
RXA.5.2 Text Pneumococcal conjugate (PCV13)
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text PREVNAR 13
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J.
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number P343V8445
RXA.16 Substance Expiration Date
RXA.16.1 Time 20120330
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PFR
RXA.17.2 Text Pfizer, Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 17
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20120521
RXA.5 Administered Code
RXA.5.1 Identifier 133
RXA.5.2 Text Pneumococcal conjugate (PCV13)
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text PREVNAR 13
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J.
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number P853V2175
RXA.16 Substance Expiration Date
RXA.16.1 Time 20120830
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PFR
RXA.17.2 Text Pfizer, Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 18
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20121122
RXA.5 Administered Code
RXA.5.1 Identifier 133
RXA.5.2 Text Pneumococcal conjugate (PCV13)
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text PREVNAR 13
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J.
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number P853V58544
RXA.16 Substance Expiration Date
RXA.16.1 Time 20130118
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PFR
RXA.17.2 Text Pfizer, Inc
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 19
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20121122
RXA.5 Administered Code
RXA.5.1 Identifier 119
RXA.5.2 Text Rotavirus
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text ROTARIX
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J.
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 6359RV543
RXA.16 Substance Expiration Date
RXA.16.1 Time 20120215
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier SKB
RXA.17.2 Text GlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 20
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20120322
RXA.5 Administered Code
RXA.5.1 Identifier 119
RXA.5.2 Text Rotavirus
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text ROTARIX
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J.
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 6359RV933
RXA.16 Substance Expiration Date
RXA.16.1 Time 20120510
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier SKB
RXA.17.2 Text GlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 21
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20120922
RXA.5 Administered Code
RXA.5.1 Identifier 161
RXA.5.2 Text Influenza
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text FLUZONE QUADRIVALENT
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J.
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D8043IN8738
RXA.16 Substance Expiration Date
RXA.16.1 Time 20130312
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi Pasteur
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 22
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20121022
RXA.5 Administered Code
RXA.5.1 Identifier 161
RXA.5.2 Text Influenza
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text FLUZONE QUADRIVALENT
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J.
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D8043IN8798
RXA.16 Substance Expiration Date
RXA.16.1 Time 20130312
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi Pasteur
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 23
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20131030
RXA.5 Administered Code
RXA.5.1 Identifier 161
RXA.5.2 Text Influenza
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text FLUZONE QUADRIVALENT
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J.
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D9334IN9433
RXA.16 Substance Expiration Date
RXA.16.1 Time 20140522
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi Pasteur
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 24
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20150715
RXA.5 Administered Code
RXA.5.1 Identifier 161
RXA.5.2 Text Influenza
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text FLUZONE QUADRIVALENT
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 0.25
RXA.7 Administered Units
RXA.7.1 Identifier mL
RXA.7.2 Text
RXA.7.3 Name of Coding System UCUM
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 00
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Molina
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name Sandra
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number D8043IN8855
RXA.16 Substance Expiration Date
RXA.16.1 Time 20150828
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier PMC
RXA.17.2 Text Sanofi Pasteur
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 25
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20130521
RXA.5 Administered Code
RXA.5.1 Identifier 83
RXA.5.2 Text Hepatitis A
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text HAVRIX
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J.
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 6359RT35
RXA.16 Substance Expiration Date
RXA.16.1 Time 20140104
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier SKB
RXA.17.2 Text GlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 26
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20131201
RXA.5 Administered Code
RXA.5.1 Identifier 83
RXA.5.2 Text Hepatitis A
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text HAVRIX
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J.
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 6359RT47
RXA.16 Substance Expiration Date
RXA.16.1 Time 20130911
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier SKB
RXA.17.2 Text GlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 27
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20130112
RXA.5 Administered Code
RXA.5.1 Identifier 94
RXA.5.2 Text MMR and Varicella
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text ProQuad
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Martinez
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name J.
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 7W27V7632
RXA.16 Substance Expiration Date
RXA.16.1 Time 20161215
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier MSD
RXA.17.2 Text Merck Sharp and Dohme Corp.
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXR - 1
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 2
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier RT
RXR.2.2 Text Right Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 3
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 4
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 5
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 6
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 7
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 8
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier RT
RXR.2.2 Text Right Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 9
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 10
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier RT
RXR.2.2 Text Right Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 11
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 12
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text SC
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text SC
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 13
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text SC
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text SC
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 14
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text SC
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text SC
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 15
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 16
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 17
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier RT
RXR.2.2 Text Right Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 18
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 19
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 20
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier RT
RXR.2.2 Text Thigh Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 21
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 22
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier RT
RXR.2.2 Text Right Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 23
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 24
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 25
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier RD
RXR.2.2 Text Right Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 26
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LD
RXR.2.2 Text Left Deltoid
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

RXR - 27
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text SC
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text SC
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

OBX - 1
Location Data Element Data Categorization
OBX.1 Set ID - OBX 2
OBX.2 Value Type TS
OBX.3 Observation Identifier
OBX.3.1 Identifier 29768-9
OBX.3.2 Text VIS Publication Date
OBX.3.3 Name of Coding System LN
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.5.1 Time 20120202
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 2
Location Data Element Data Categorization
OBX.1 Set ID - OBX 3
OBX.2 Value Type TS
OBX.3 Observation Identifier
OBX.3.1 Identifier 29769-7
OBX.3.2 Text VIS Presentation Date
OBX.3.3 Name of Coding System LN
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.5.1 Time 20150715
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 3
Location Data Element Data Categorization
OBX.1 Set ID - OBX 1
OBX.2 Value Type CE
OBX.3 Observation Identifier
OBX.3.1 Identifier 64994-7
OBX.3.2 Text vaccine fund pgm elig cat
OBX.3.3 Name of Coding System LN
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 4
Location Data Element Data Categorization
OBX.1 Set ID - OBX 2
OBX.2 Value Type TS
OBX.3 Observation Identifier
OBX.3.1 Identifier 29768-9
OBX.3.2 Text VIS Publication Date
OBX.3.3 Name of Coding System LN
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.5.1 Time 20140819
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 5
Location Data Element Data Categorization
OBX.1 Set ID - OBX 3
OBX.2 Value Type TS
OBX.3 Observation Identifier
OBX.3.1 Identifier 29769-7
OBX.3.2 Text VIS Presentation Date
OBX.3.3 Name of Coding System LN
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.5.1 Time 20150715
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 6
Location Data Element Data Categorization
OBX.1 Set ID - OBX 1
OBX.2 Value Type CE
OBX.3 Observation Identifier
OBX.3.1 Identifier 64994-7
OBX.3.2 Text vaccine fund pgm elig cat
OBX.3.3 Name of Coding System LN
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

Test Data Specification

Patient Information
Element Data
Patient Name Juan Marcel Gonzales
Mother's Maiden Name Anita Morales
ID Number 123456 987633
Date/Time of Birth 11/23/2011
Administrative Sex Male
Patient Address 4623 Standish Way Stamford CT 06903 USA
Local Number (203)555-1213
Race Other Race
Ethnic Group Hispanic or Latino
Birth Order
Immunization Registry Information
Element Data
Immunization Registry Status A
Immunization Registry Status Effective Date 07/01/2012
Publicity Code Reminder/Recall - any method
Publicity Code Effective Date 07/01/2012
Protection Indicator
Protection Indicator Effective Date
Guardian or Responsible Party
Element Data
Name Manuel Marcel Gonzales
Relationship Father
Address 4623 Standish Way Stamford CT 06903
Phone Number (203)555-1213

Vaccine Administration Information[*]
Vaccine Administration Information - 1
Element Data
Administered Code Hepatitis B
Date/Time Start of Administration 11/23/2011
Administered Amount 999
Administered Units
Administration Notes
Administering Provider J. Martinez
Substance Lot Number 6332FK34
Substance Expiration Date 12/14/2011
Substance Manufacturer Name GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Thigh
Entering Organization Shoreline Hospital
Entered By Lisa Sirtis
Ordered By Jane Carter

Vaccine Administration Information - 2
Element Data
Administered Code Hepatitis B
Date/Time Start of Administration 12/23/2011
Administered Amount 999
Administered Units
Administration Notes
Administering Provider J. Martinez
Substance Lot Number 6352FK2
Substance Expiration Date 10/01/2011
Substance Manufacturer Name GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Right Thigh
Entering Organization Oceanview Pediatrics
Entered By J. Martinez
Ordered By J. Rodriguez

Vaccine Administration Information - 3
Element Data
Administered Code Hepatitis B
Date/Time Start of Administration 07/15/2015
Administered Amount 0.5
Administered Units
Administration Notes
Administering Provider Sandra Molina
Substance Lot Number 6332FK26
Substance Expiration Date 08/25/2015
Substance Manufacturer Name GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Deltoid
Entering Organization Shoreline Pediatrics
Entered By Sandra Molina
Ordered By Frank Smith

Element Data
VIS Publication Date 02/02/2012
VIS Presentation Date 07/15/2015
vaccine fund pgm elig cat Not VFC elig

Vaccine Administration Information - 4
Element Data
Administered Code DTaP
Date/Time Start of Administration 01/22/2012
Administered Amount 999
Administered Units
Administration Notes
Administering Provider J. Martinez
Substance Lot Number D409QS2342
Substance Expiration Date 11/30/2012
Substance Manufacturer Name Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Thigh
Entering Organization Oceanview Pediatrics
Entered By J. Martinez
Ordered By J. Rodriguez

Vaccine Administration Information - 5
Element Data
Administered Code DTaP
Date/Time Start of Administration 03/22/2012
Administered Amount 999
Administered Units
Administration Notes
Administering Provider J. Martinez
Substance Lot Number D409QS2434
Substance Expiration Date 09/04/2012
Substance Manufacturer Name Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Thigh
Entering Organization Oceanview Pediatrics
Entered By J. Martinez
Ordered By J. Rodriguez

Vaccine Administration Information - 6
Element Data
Administered Code DTaP
Date/Time Start of Administration 05/21/2012
Administered Amount 999
Administered Units
Administration Notes
Administering Provider J. Martinez
Substance Lot Number D409QS250
Substance Expiration Date 01/03/2014
Substance Manufacturer Name Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J. Martinez
Ordered By J. Rodriguez

Vaccine Administration Information - 7
Element Data
Administered Code DTaP
Date/Time Start of Administration 02/20/2013
Administered Amount 999
Administered Units
Administration Notes
Administering Provider J. Martinez
Substance Lot Number D409QS250
Substance Expiration Date 01/03/2014
Substance Manufacturer Name Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J. Martinez
Ordered By J. Rodriguez

Vaccine Administration Information - 8
Element Data
Administered Code Hib
Date/Time Start of Administration 01/22/2012
Administered Amount 999
Administered Units
Administration Notes
Administering Provider J. Martinez
Substance Lot Number 7M54K9255
Substance Expiration Date 03/24/2012
Substance Manufacturer Name Merck Sharp and Dohme Corp.
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Right Thigh
Entering Organization Oceanview Pediatrics
Entered By J. Martinez
Ordered By J. Rodriguez

Vaccine Administration Information - 9
Element Data
Administered Code Hib
Date/Time Start of Administration 03/22/2012
Administered Amount 999
Administered Units
Administration Notes
Administering Provider J. Martinez
Substance Lot Number 7M55K3343
Substance Expiration Date 10/30/2012
Substance Manufacturer Name Merck Sharp and Dohme Corp.
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Thigh
Entering Organization Oceanview Pediatrics
Entered By J. Martinez
Ordered By J. Rodriguez

Vaccine Administration Information - 10
Element Data
Administered Code Hib
Date/Time Start of Administration 05/12/2012
Administered Amount 999
Administered Units
Administration Notes
Administering Provider J. Martinez
Substance Lot Number 7M75K4577
Substance Expiration Date 05/23/2012
Substance Manufacturer Name Merck Sharp and Dohme Corp.
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Right Thigh
Entering Organization Oceanview Pediatrics
Entered By J. Martinez
Ordered By J. Rodriguez

Vaccine Administration Information - 11
Element Data
Administered Code Hib
Date/Time Start of Administration 02/22/2012
Administered Amount 999
Administered Units
Administration Notes
Administering Provider J. Martinez
Substance Lot Number 7M53K5535
Substance Expiration Date 02/22/2012
Substance Manufacturer Name Merck Sharp and Dohme Corp.
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J. Martinez
Ordered By J. Rodriguez

Vaccine Administration Information - 12
Element Data
Administered Code Polio (IPV)
Date/Time Start of Administration 01/22/2012
Administered Amount 999
Administered Units
Administration Notes
Administering Provider J. Martinez
Substance Lot Number D333PV2444
Substance Expiration Date 04/10/2012
Substance Manufacturer Name MSanofi Pasteur Inc.
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route SC
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J. Martinez
Ordered By J. Rodriguez

Vaccine Administration Information - 13
Element Data
Administered Code Polio (IPV)
Date/Time Start of Administration 03/22/2012
Administered Amount 999
Administered Units
Administration Notes
Administering Provider J. Martinez
Substance Lot Number D333PV4343
Substance Expiration Date 03/23/2012
Substance Manufacturer Name MSanofi Pasteur Inc.
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route SC
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J. Martinez
Ordered By J. Rodriguez

Vaccine Administration Information - 14
Element Data
Administered Code Polio (IPV)
Date/Time Start of Administration 05/21/2012
Administered Amount 999
Administered Units
Administration Notes
Administering Provider J. Martinez
Substance Lot Number D333PV4343
Substance Expiration Date 03/23/2012
Substance Manufacturer Name MSanofi Pasteur Inc.
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route SC
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J. Martinez
Ordered By J. Rodriguez

Vaccine Administration Information - 15
Element Data
Administered Code Pneumococcal conjugate (PCV13)
Date/Time Start of Administration 01/22/2012
Administered Amount 999
Administered Units
Administration Notes
Administering Provider J. Martinez
Substance Lot Number P243V3321
Substance Expiration Date 01/30/2012
Substance Manufacturer Name Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Thigh
Entering Organization Oceanview Pediatrics
Entered By J. Martinez
Ordered By J. Rodriguez

Vaccine Administration Information - 16
Element Data
Administered Code Pneumococcal conjugate (PCV13)
Date/Time Start of Administration 03/22/2012
Administered Amount 999
Administered Units
Administration Notes
Administering Provider J. Martinez
Substance Lot Number P343V8445
Substance Expiration Date 03/30/2012
Substance Manufacturer Name Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Thigh
Entering Organization Oceanview Pediatrics
Entered By J. Martinez
Ordered By J. Rodriguez

Vaccine Administration Information - 17
Element Data
Administered Code Pneumococcal conjugate (PCV13)
Date/Time Start of Administration 05/21/2012
Administered Amount 999
Administered Units
Administration Notes
Administering Provider J. Martinez
Substance Lot Number P853V2175
Substance Expiration Date 08/30/2012
Substance Manufacturer Name Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Right Thigh
Entering Organization Oceanview Pediatrics
Entered By J. Martinez
Ordered By J. Rodriguez

Vaccine Administration Information - 18
Element Data
Administered Code Pneumococcal conjugate (PCV13)
Date/Time Start of Administration 11/22/2012
Administered Amount 999
Administered Units
Administration Notes
Administering Provider J. Martinez
Substance Lot Number P853V58544
Substance Expiration Date 01/18/2013
Substance Manufacturer Name Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J. Martinez
Ordered By J. Rodriguez

Vaccine Administration Information - 19
Element Data
Administered Code Rotavirus
Date/Time Start of Administration 11/22/2012
Administered Amount 999
Administered Units
Administration Notes
Administering Provider J. Martinez
Substance Lot Number 6359RV543
Substance Expiration Date 02/15/2012
Substance Manufacturer Name GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Thigh
Entering Organization Oceanview Pediatrics
Entered By J. Martinez
Ordered By J. Rodriguez

Vaccine Administration Information - 20
Element Data
Administered Code Rotavirus
Date/Time Start of Administration 03/22/2012
Administered Amount 999
Administered Units
Administration Notes
Administering Provider J. Martinez
Substance Lot Number 6359RV933
Substance Expiration Date 05/10/2012
Substance Manufacturer Name GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Thigh Thigh
Entering Organization Oceanview Pediatrics
Entered By J. Martinez
Ordered By J. Rodriguez

Vaccine Administration Information - 21
Element Data
Administered Code Influenza
Date/Time Start of Administration 09/22/2012
Administered Amount 999
Administered Units
Administration Notes
Administering Provider J. Martinez
Substance Lot Number D8043IN8738
Substance Expiration Date 03/12/2013
Substance Manufacturer Name Sanofi Pasteur
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Thigh
Entering Organization Oceanview Pediatrics
Entered By J. Martinez
Ordered By J. Rodriguez

Vaccine Administration Information - 22
Element Data
Administered Code Influenza
Date/Time Start of Administration 10/22/2012
Administered Amount 999
Administered Units
Administration Notes
Administering Provider J. Martinez
Substance Lot Number D8043IN8798
Substance Expiration Date 03/12/2013
Substance Manufacturer Name Sanofi Pasteur
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Right Thigh
Entering Organization Oceanview Pediatrics
Entered By J. Martinez
Ordered By J. Rodriguez

Vaccine Administration Information - 23
Element Data
Administered Code Influenza
Date/Time Start of Administration 10/30/2013
Administered Amount 999
Administered Units
Administration Notes
Administering Provider J. Martinez
Substance Lot Number D9334IN9433
Substance Expiration Date 05/22/2014
Substance Manufacturer Name Sanofi Pasteur
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J. Martinez
Ordered By J. Rodriguez

Vaccine Administration Information - 24
Element Data
Administered Code Influenza
Date/Time Start of Administration 07/15/2015
Administered Amount 0.25
Administered Units
Administration Notes
Administering Provider Sandra Molina
Substance Lot Number D8043IN8855
Substance Expiration Date 08/28/2015
Substance Manufacturer Name Sanofi Pasteur
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Deltoid
Entering Organization Shoreline Pediatrics
Entered By Sandra Molina
Ordered By Frank Smith

Element Data
VIS Publication Date 08/19/2014
VIS Presentation Date 07/15/2015
vaccine fund pgm elig cat Not VFC elig

Vaccine Administration Information - 25
Element Data
Administered Code Hepatitis A
Date/Time Start of Administration 05/21/2013
Administered Amount 999
Administered Units
Administration Notes
Administering Provider J. Martinez
Substance Lot Number 6359RT35
Substance Expiration Date 01/04/2014
Substance Manufacturer Name GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Right Deltoid
Entering Organization Oceanview Pediatrics
Entered By J. Martinez
Ordered By J. Rodriguez

Vaccine Administration Information - 26
Element Data
Administered Code Hepatitis A
Date/Time Start of Administration 12/01/2013
Administered Amount 999
Administered Units
Administration Notes
Administering Provider J. Martinez
Substance Lot Number 6359RT47
Substance Expiration Date 09/11/2013
Substance Manufacturer Name GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J. Martinez
Ordered By J. Rodriguez

Vaccine Administration Information - 27
Element Data
Administered Code MMR and Varicella
Date/Time Start of Administration 01/12/2013
Administered Amount 999
Administered Units
Administration Notes
Administering Provider J. Martinez
Substance Lot Number 7W27V7632
Substance Expiration Date 12/15/2016
Substance Manufacturer Name Merck Sharp and Dohme Corp.
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route SC
Administration Site Left Thigh
Entering Organization Oceanview Pediatrics
Entered By J. Martinez
Ordered By J. Rodriguez
Element Data
Patient Name Juan Marcel Gonzales
Mother's Maiden Name Anita Morales
ID Number 123456 987633
Date/Time of Birth 11/23/2011
Administrative Sex Male
Patient Address 4623 Standish Way Stamford CT 06903 USA
Local Number (203)555-1213
Race Other Race
Ethnic Group Hispanic or Latino
Birth Order
Element Data
Immunization Registry Status A
Immunization Registry Status Effective Date 07/01/2012
Publicity Code Reminder/Recall - any method
Publicity Code Effective Date 07/01/2012
Protection Indicator
Protection Indicator Effective Date
Element Data
Name Manuel Marcel Gonzales
Relationship Father
Address 4623 Standish Way Stamford CT 06903
Phone Number (203)555-1213
Vaccine Administration Information - 1
Element Data
Administered Code Hepatitis B
Date/Time Start of Administration 11/23/2011
Administered Amount 999
Administered Units
Administration Notes
Administering Provider J. Martinez
Substance Lot Number 6332FK34
Substance Expiration Date 12/14/2011
Substance Manufacturer Name GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Thigh
Entering Organization Shoreline Hospital
Entered By Lisa Sirtis
Ordered By Jane Carter

 Vaccine Administration Information - 2
Element Data
Administered Code Hepatitis B
Date/Time Start of Administration 12/23/2011
Administered Amount 999
Administered Units
Administration Notes
Administering Provider J. Martinez
Substance Lot Number 6352FK2
Substance Expiration Date 10/01/2011
Substance Manufacturer Name GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Right Thigh
Entering Organization Oceanview Pediatrics
Entered By J. Martinez
Ordered By J. Rodriguez

 Vaccine Administration Information - 3
Element Data
Administered Code Hepatitis B
Date/Time Start of Administration 07/15/2015
Administered Amount 0.5
Administered Units
Administration Notes
Administering Provider Sandra Molina
Substance Lot Number 6332FK26
Substance Expiration Date 08/25/2015
Substance Manufacturer Name GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Deltoid
Entering Organization Shoreline Pediatrics
Entered By Sandra Molina
Ordered By Frank Smith

Element Data
VIS Publication Date 02/02/2012
VIS Presentation Date 07/15/2015
vaccine fund pgm elig cat Not VFC elig

 Vaccine Administration Information - 4
Element Data
Administered Code DTaP
Date/Time Start of Administration 01/22/2012
Administered Amount 999
Administered Units
Administration Notes
Administering Provider J. Martinez
Substance Lot Number D409QS2342
Substance Expiration Date 11/30/2012
Substance Manufacturer Name Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Thigh
Entering Organization Oceanview Pediatrics
Entered By J. Martinez
Ordered By J. Rodriguez

 Vaccine Administration Information - 5
Element Data
Administered Code DTaP
Date/Time Start of Administration 03/22/2012
Administered Amount 999
Administered Units
Administration Notes
Administering Provider J. Martinez
Substance Lot Number D409QS2434
Substance Expiration Date 09/04/2012
Substance Manufacturer Name Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Thigh
Entering Organization Oceanview Pediatrics
Entered By J. Martinez
Ordered By J. Rodriguez

 Vaccine Administration Information - 6
Element Data
Administered Code DTaP
Date/Time Start of Administration 05/21/2012
Administered Amount 999
Administered Units
Administration Notes
Administering Provider J. Martinez
Substance Lot Number D409QS250
Substance Expiration Date 01/03/2014
Substance Manufacturer Name Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J. Martinez
Ordered By J. Rodriguez

 Vaccine Administration Information - 7
Element Data
Administered Code DTaP
Date/Time Start of Administration 02/20/2013
Administered Amount 999
Administered Units
Administration Notes
Administering Provider J. Martinez
Substance Lot Number D409QS250
Substance Expiration Date 01/03/2014
Substance Manufacturer Name Sanofi Pasteur Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J. Martinez
Ordered By J. Rodriguez

 Vaccine Administration Information - 8
Element Data
Administered Code Hib
Date/Time Start of Administration 01/22/2012
Administered Amount 999
Administered Units
Administration Notes
Administering Provider J. Martinez
Substance Lot Number 7M54K9255
Substance Expiration Date 03/24/2012
Substance Manufacturer Name Merck Sharp and Dohme Corp.
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Right Thigh
Entering Organization Oceanview Pediatrics
Entered By J. Martinez
Ordered By J. Rodriguez

 Vaccine Administration Information - 9
Element Data
Administered Code Hib
Date/Time Start of Administration 03/22/2012
Administered Amount 999
Administered Units
Administration Notes
Administering Provider J. Martinez
Substance Lot Number 7M55K3343
Substance Expiration Date 10/30/2012
Substance Manufacturer Name Merck Sharp and Dohme Corp.
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Thigh
Entering Organization Oceanview Pediatrics
Entered By J. Martinez
Ordered By J. Rodriguez

 Vaccine Administration Information - 10
Element Data
Administered Code Hib
Date/Time Start of Administration 05/12/2012
Administered Amount 999
Administered Units
Administration Notes
Administering Provider J. Martinez
Substance Lot Number 7M75K4577
Substance Expiration Date 05/23/2012
Substance Manufacturer Name Merck Sharp and Dohme Corp.
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Right Thigh
Entering Organization Oceanview Pediatrics
Entered By J. Martinez
Ordered By J. Rodriguez

 Vaccine Administration Information - 11
Element Data
Administered Code Hib
Date/Time Start of Administration 02/22/2012
Administered Amount 999
Administered Units
Administration Notes
Administering Provider J. Martinez
Substance Lot Number 7M53K5535
Substance Expiration Date 02/22/2012
Substance Manufacturer Name Merck Sharp and Dohme Corp.
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J. Martinez
Ordered By J. Rodriguez

 Vaccine Administration Information - 12
Element Data
Administered Code Polio (IPV)
Date/Time Start of Administration 01/22/2012
Administered Amount 999
Administered Units
Administration Notes
Administering Provider J. Martinez
Substance Lot Number D333PV2444
Substance Expiration Date 04/10/2012
Substance Manufacturer Name MSanofi Pasteur Inc.
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route SC
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J. Martinez
Ordered By J. Rodriguez

 Vaccine Administration Information - 13
Element Data
Administered Code Polio (IPV)
Date/Time Start of Administration 03/22/2012
Administered Amount 999
Administered Units
Administration Notes
Administering Provider J. Martinez
Substance Lot Number D333PV4343
Substance Expiration Date 03/23/2012
Substance Manufacturer Name MSanofi Pasteur Inc.
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route SC
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J. Martinez
Ordered By J. Rodriguez

 Vaccine Administration Information - 14
Element Data
Administered Code Polio (IPV)
Date/Time Start of Administration 05/21/2012
Administered Amount 999
Administered Units
Administration Notes
Administering Provider J. Martinez
Substance Lot Number D333PV4343
Substance Expiration Date 03/23/2012
Substance Manufacturer Name MSanofi Pasteur Inc.
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route SC
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J. Martinez
Ordered By J. Rodriguez

 Vaccine Administration Information - 15
Element Data
Administered Code Pneumococcal conjugate (PCV13)
Date/Time Start of Administration 01/22/2012
Administered Amount 999
Administered Units
Administration Notes
Administering Provider J. Martinez
Substance Lot Number P243V3321
Substance Expiration Date 01/30/2012
Substance Manufacturer Name Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Thigh
Entering Organization Oceanview Pediatrics
Entered By J. Martinez
Ordered By J. Rodriguez

 Vaccine Administration Information - 16
Element Data
Administered Code Pneumococcal conjugate (PCV13)
Date/Time Start of Administration 03/22/2012
Administered Amount 999
Administered Units
Administration Notes
Administering Provider J. Martinez
Substance Lot Number P343V8445
Substance Expiration Date 03/30/2012
Substance Manufacturer Name Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Thigh
Entering Organization Oceanview Pediatrics
Entered By J. Martinez
Ordered By J. Rodriguez

 Vaccine Administration Information - 17
Element Data
Administered Code Pneumococcal conjugate (PCV13)
Date/Time Start of Administration 05/21/2012
Administered Amount 999
Administered Units
Administration Notes
Administering Provider J. Martinez
Substance Lot Number P853V2175
Substance Expiration Date 08/30/2012
Substance Manufacturer Name Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Right Thigh
Entering Organization Oceanview Pediatrics
Entered By J. Martinez
Ordered By J. Rodriguez

 Vaccine Administration Information - 18
Element Data
Administered Code Pneumococcal conjugate (PCV13)
Date/Time Start of Administration 11/22/2012
Administered Amount 999
Administered Units
Administration Notes
Administering Provider J. Martinez
Substance Lot Number P853V58544
Substance Expiration Date 01/18/2013
Substance Manufacturer Name Pfizer, Inc
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J. Martinez
Ordered By J. Rodriguez

 Vaccine Administration Information - 19
Element Data
Administered Code Rotavirus
Date/Time Start of Administration 11/22/2012
Administered Amount 999
Administered Units
Administration Notes
Administering Provider J. Martinez
Substance Lot Number 6359RV543
Substance Expiration Date 02/15/2012
Substance Manufacturer Name GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Thigh
Entering Organization Oceanview Pediatrics
Entered By J. Martinez
Ordered By J. Rodriguez

 Vaccine Administration Information - 20
Element Data
Administered Code Rotavirus
Date/Time Start of Administration 03/22/2012
Administered Amount 999
Administered Units
Administration Notes
Administering Provider J. Martinez
Substance Lot Number 6359RV933
Substance Expiration Date 05/10/2012
Substance Manufacturer Name GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Thigh Thigh
Entering Organization Oceanview Pediatrics
Entered By J. Martinez
Ordered By J. Rodriguez

 Vaccine Administration Information - 21
Element Data
Administered Code Influenza
Date/Time Start of Administration 09/22/2012
Administered Amount 999
Administered Units
Administration Notes
Administering Provider J. Martinez
Substance Lot Number D8043IN8738
Substance Expiration Date 03/12/2013
Substance Manufacturer Name Sanofi Pasteur
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Thigh
Entering Organization Oceanview Pediatrics
Entered By J. Martinez
Ordered By J. Rodriguez

 Vaccine Administration Information - 22
Element Data
Administered Code Influenza
Date/Time Start of Administration 10/22/2012
Administered Amount 999
Administered Units
Administration Notes
Administering Provider J. Martinez
Substance Lot Number D8043IN8798
Substance Expiration Date 03/12/2013
Substance Manufacturer Name Sanofi Pasteur
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Right Thigh
Entering Organization Oceanview Pediatrics
Entered By J. Martinez
Ordered By J. Rodriguez

 Vaccine Administration Information - 23
Element Data
Administered Code Influenza
Date/Time Start of Administration 10/30/2013
Administered Amount 999
Administered Units
Administration Notes
Administering Provider J. Martinez
Substance Lot Number D9334IN9433
Substance Expiration Date 05/22/2014
Substance Manufacturer Name Sanofi Pasteur
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J. Martinez
Ordered By J. Rodriguez

 Vaccine Administration Information - 24
Element Data
Administered Code Influenza
Date/Time Start of Administration 07/15/2015
Administered Amount 0.25
Administered Units
Administration Notes
Administering Provider Sandra Molina
Substance Lot Number D8043IN8855
Substance Expiration Date 08/28/2015
Substance Manufacturer Name Sanofi Pasteur
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Deltoid
Entering Organization Shoreline Pediatrics
Entered By Sandra Molina
Ordered By Frank Smith

Element Data
VIS Publication Date 08/19/2014
VIS Presentation Date 07/15/2015
vaccine fund pgm elig cat Not VFC elig

 Vaccine Administration Information - 25
Element Data
Administered Code Hepatitis A
Date/Time Start of Administration 05/21/2013
Administered Amount 999
Administered Units
Administration Notes
Administering Provider J. Martinez
Substance Lot Number 6359RT35
Substance Expiration Date 01/04/2014
Substance Manufacturer Name GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Right Deltoid
Entering Organization Oceanview Pediatrics
Entered By J. Martinez
Ordered By J. Rodriguez

 Vaccine Administration Information - 26
Element Data
Administered Code Hepatitis A
Date/Time Start of Administration 12/01/2013
Administered Amount 999
Administered Units
Administration Notes
Administering Provider J. Martinez
Substance Lot Number 6359RT47
Substance Expiration Date 09/11/2013
Substance Manufacturer Name GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Deltoid
Entering Organization Oceanview Pediatrics
Entered By J. Martinez
Ordered By J. Rodriguez

 Vaccine Administration Information - 27
Element Data
Administered Code MMR and Varicella
Date/Time Start of Administration 01/12/2013
Administered Amount 999
Administered Units
Administration Notes
Administering Provider J. Martinez
Substance Lot Number 7W27V7632
Substance Expiration Date 12/15/2016
Substance Manufacturer Name Merck Sharp and Dohme Corp.
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route SC
Administration Site Left Thigh
Entering Organization Oceanview Pediatrics
Entered By J. Martinez
Ordered By J. Rodriguez

4.3. Mariela Gonzales Morales Transmit Immunization Report

Send the Immunization Report to the Immunization Registry (VXU/Z22) for Mariela Gonzales Morales.

Test Story

Description
No Description

Comments
No Comments

PreCondition
No PreCondition

PostCondition
No PostCondition

Test Objectives
No Test Objectives

Evaluation Criteria
No evaluation criteria

Notes to Testers
No Note

4.3.1. Transmit the Immunization Report for Mariela Gonzales Morales

Test Step Type: SUT_INITIATOR
The EMR sends the Immunization Report to the Immunization Registry (VXU/Z22) for updated vaccination information from the visit. This includes the vaccine deferral and may include historical information updated in the EMR during the visit.

Test Story

Description

Following the visit, the EMR transmits an Immunization report to the Immunization Registry using the VXU/Z22. The Vaccination report includes the vaccine deferrals. The report MAY send the immunizations that the EMR imported from the IIS.

Comments

The Report must include all vaccine deferrals recorded in the EMR in any order. The report may include the information imported from the IIS

PreCondition

The vaccines for the visit have been administered.

PostCondition

The Immunization Report has been transmitted to the IIS using a valid Z22 VXU in accordance with the test data correctly and without omission.

Test Objectives

Transmit Standard Patient Immunization History Report: The EHR or other clinical software system directly or indirectly through an intermediary creates and transmits a report of a patient's immunization history to public health immunization registries.

Evaluation Criteria

The VXU/Z22 message passes validation using the NIST Immunization VXU Validation Tool (Z22) (context-free). The content of the message correctly reflects the test data (context-based) in accordance with the Test Data Specification and the Message Content. The message must contain all deferrals recorded in the EMR. Current Date is expected for the Non-Administration date and deferral date.

Notes to Testers

No Note

Message Contents

MSH
Location Data Element Data Categorization
MSH.1 Field Separator |
MSH.2 Encoding Characters ^~\&
MSH.3 Sending Application
MSH.3.1 Namespace ID Test EHR Application
MSH.3.2 Universal ID
MSH.3.3 Universal ID Type
MSH.4 Sending Facility
MSH.4.1 Namespace ID X68
MSH.4.2 Universal ID
MSH.4.3 Universal ID Type
MSH.5 Receiving Application
MSH.5.1 Namespace ID
MSH.5.2 Universal ID
MSH.5.3 Universal ID Type
MSH.6 Receiving Facility
MSH.6.1 Namespace ID NIST Test Iz Reg
MSH.6.2 Universal ID
MSH.6.3 Universal ID Type
MSH.7 Date/Time Of Message
MSH.7.1 Time 20120701082240-0500
MSH.9 Message Type
MSH.9.1 Message Code VXU
MSH.9.2 Trigger Event V04
MSH.9.3 Message Structure VXU_V04
MSH.10 Message Control ID NIST-IZ-001.00
MSH.11 Processing ID
MSH.11.1 Processing ID P
MSH.12 Version ID
MSH.12.1 Version ID 2.5.1
MSH.15 Accept Acknowledgment Type ER
MSH.16 Application Acknowledgment Type AL
MSH.21 Message Profile Identifier
MSH.21.1 Entity Identifier Z22
MSH.21.2 Namespace ID CDCPHINVS
MSH.21.3 Universal ID
MSH.21.4 Universal ID Type
MSH.22 Sending Responsible Organization
MSH.22.1 Organization Name
MSH.22.6 Assigning Authority
MSH.22.6.1 Namespace ID
MSH.22.6.2 Universal ID
MSH.22.6.3 Universal ID Type
MSH.22.7 Identifier Type Code
MSH.22.10 Organization Identifier
MSH.23 Receiving Responsible Organization
MSH.23.1 Organization Name
MSH.23.6 Assigning Authority
MSH.23.6.1 Namespace ID
MSH.23.6.2 Universal ID
MSH.23.6.3 Universal ID Type
MSH.23.7 Identifier Type Code
MSH.23.10 Organization Identifier

PID
Location Data Element Data Categorization
PID.1 Set ID - PID 1
PID.3 Patient Identifier List
PID.3.1 ID Number 123456
PID.3.3 Check Digit Scheme
PID.3.4 Assigning Authority
PID.3.4.1 Namespace ID MYEHR
PID.3.4.2 Universal ID
PID.3.4.3 Universal ID Type
PID.3.5 Identifier Type Code MR
PID.3 Patient Identifier List
PID.3.1 ID Number 987633
PID.3.3 Check Digit Scheme
PID.3.4 Assigning Authority
PID.3.4.1 Namespace ID MYIIS
PID.3.4.2 Universal ID
PID.3.4.3 Universal ID Type
PID.3.5 Identifier Type Code SR
PID.5 Patient Name
PID.5.1 Family Name
PID.5.1.1 Surname Morales
PID.5.1.2 Own Surname Prefix
PID.5.1.3 Own Surname
PID.5.1.4 Surname Prefix From Partner/Spouse
PID.5.1.5 Surname From Partner/Spouse
PID.5.2 Given Name Mariela Test Case Fixed
PID.5.3 Second and Further Given Names or Initials Thereof Gonzales Test Case Fixed
PID.5.7 Name Type Code L Test Case Fixed
PID.6 Mother's Maiden Name
PID.6.1 Family Name
PID.6.1.1 Surname Gonzales Test Case Fixed
PID.6.1.2 Own Surname Prefix
PID.6.1.3 Own Surname
PID.6.1.4 Surname Prefix From Partner/Spouse
PID.6.1.5 Surname From Partner/Spouse
PID.6.7 Name Type Code M Test Case Fixed
PID.7 Date/Time of Birth
PID.7.1 Time 201503301115 Test Case Fixed
PID.8 Administrative Sex F Test Case Fixed
PID.10 Race
PID.10.1 Identifier 2131-1 Test Case Fixed
PID.10.2 Text Other Race Test Case Fixed
PID.10.3 Name of Coding System HL70005 Test Case Fixed
PID.10.5 Alternate Text
PID.10.6 Name of Alternate Coding System
PID.11 Patient Address
PID.11.1 Street Address
PID.11.1.1 Street or Mailing Address 3321 Standish Way Test Case Fixed
PID.11.1.2 Street Name
PID.11.1.3 Dwelling Number
PID.11.2 Other Designation
PID.11.3 City Stamford Test Case Fixed
PID.11.4 State or Province CT Test Case Fixed
PID.11.5 Zip or Postal Code 06903 Test Case Fixed
PID.11.6 Country USA Test Case Fixed
PID.11.7 Address Type L Test Case Fixed
PID.11 Patient Address
PID.11.1 Street Address
PID.11.1.1 Street or Mailing Address 325 Shorline Drive
PID.11.1.2 Street Name
PID.11.1.3 Dwelling Number
PID.11.2 Other Designation
PID.11.3 City Stamford
PID.11.4 State or Province CT Test Case Fixed
PID.11.5 Zip or Postal Code 06901
PID.11.6 Country
PID.11.7 Address Type BDL Test Case Fixed
PID.13 Phone Number - Home
PID.13.2 Telecommunication Use Code PRN Test Case Fixed
PID.13.3 Telecommunication Equipment Type PH Test Case Fixed
PID.13.4 Email Address
PID.13.6 Area/City Code 203 Test Case Fixed
PID.13.7 Local Number 5551214 Test Case Fixed
PID.22 Ethnic Group
PID.22.1 Identifier 2135-2 Test Case Fixed
PID.22.2 Text Hispanic or Latino Test Case Fixed
PID.22.3 Name of Coding System CDCREC Test Case Fixed
PID.22.5 Alternate Text
PID.22.6 Name of Alternate Coding System
PID.24 Multiple Birth Indicator
PID.25 Birth Order
PID.29 Patient Death Date and Time
PID.29.1 Time
PID.30 Patient Death Indicator

PD1
Location Data Element Data Categorization
PD1.11 Publicity Code
PD1.11.1 Identifier 02
PD1.11.2 Text Reminder/Recall - any method
PD1.11.3 Name of Coding System HL70215
PD1.11.5 Alternate Text
PD1.11.6 Name of Alternate Coding System
PD1.12 Protection Indicator
PD1.13 Protection Indicator Effective Date
PD1.16 Immunization Registry Status A
PD1.17 Immunization Registry Status Effective Date 20120701
PD1.18 Publicity Code Effective Date 20120701

NK1
Location Data Element Data Categorization
NK1.1 Set ID - NK1 1
NK1.2 Name
NK1.2.1 Family Name
NK1.2.1.1 Surname Morales Test Case Fixed
NK1.2.1.2 Own Surname Prefix
NK1.2.1.3 Own Surname
NK1.2.1.4 Surname Prefix From Partner/Spouse
NK1.2.1.5 Surname From Partner/Spouse
NK1.2.2 Given Name Joanna Test Case Fixed
NK1.2.3 Second and Further Given Names or Initials Thereof Gonzales Test Case Fixed
NK1.2.7 Name Type Code L Test Case Fixed
NK1.3 Relationship
NK1.3.1 Identifier MTH Test Case Fixed
NK1.3.2 Text Mother Test Case Fixed
NK1.3.3 Name of Coding System HL70063
NK1.3.5 Alternate Text
NK1.3.6 Name of Alternate Coding System
NK1.4 Address
NK1.4.1 Street Address
NK1.4.1.1 Street or Mailing Address 4623 Standish Way Test Case Fixed
NK1.4.1.2 Street Name
NK1.4.1.3 Dwelling Number
NK1.4.2 Other Designation
NK1.4.3 City Stamford Test Case Fixed
NK1.4.4 State or Province CT Test Case Fixed
NK1.4.5 Zip or Postal Code 06903 Test Case Fixed
NK1.4.6 Country
NK1.4.7 Address Type L Test Case Fixed
NK1.5 Phone Number
NK1.5.2 Telecommunication Use Code PRN Test Case Fixed
NK1.5.3 Telecommunication Equipment Type PH Test Case Fixed
NK1.5.4 Email Address
NK1.5.6 Area/City Code 203 Test Case Fixed
NK1.5.7 Local Number 5551213 Test Case Fixed

ORC[*]
ORC - 1
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Sirtis Test Case Fixed
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name Lisa
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Carter
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Jane
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier SH
ORC.17.2 Text Shoreline Hospital
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 2
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 9999
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Molina Test Case Fixed
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name Sandra Test Case Fixed
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Smith Test Case Fixed
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Frank Test Case Fixed
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L Test Case Fixed
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier SP
ORC.17.2 Text Shoreline Pediatrics Test Case Fixed
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 3
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 9999
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Molina Test Case Fixed
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name Sandra Test Case Fixed
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Smith Test Case Fixed
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Frank Test Case Fixed
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier SP
ORC.17.2 Text Shoreline Pediatrics Test Case Fixed
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 4
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 9999
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Molina Test Case Fixed
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name Sandra Test Case Fixed
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Smith Test Case Fixed
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Frank Test Case Fixed
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L Test Case Fixed
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier SP
ORC.17.2 Text Shoreline Pediatrics Test Case Fixed
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 5
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 9999
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Molina Test Case Fixed
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name Sandra Test Case Fixed
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Smith Test Case Fixed
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Frank Test Case Fixed
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L Test Case Fixed
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier SP
ORC.17.2 Text Shoreline Pediatrics Test Case Fixed
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 6
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 9999
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Molina Test Case Fixed
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name Sandra Test Case Fixed
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Smith Test Case Fixed
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Frank Test Case Fixed
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier SP
ORC.17.2 Text Shoreline Pediatrics Test Case Fixed
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

RXA[*]
RXA - 1
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20091123
RXA.5 Administered Code
RXA.5.1 Identifier 08
RXA.5.2 Text hepatitis B vaccine, pediatric or pediatric/adolescent dosage
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text ENGERIX-B
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Sirtis
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name Lisa
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 6332FK33
RXA.16 Substance Expiration Date
RXA.16.1 Time 20101214
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier SKB
RXA.17.2 Text GlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 2
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20150715
RXA.5 Administered Code
RXA.5.1 Identifier 45 Test Case Fixed
RXA.5.2 Text hepatitis B vaccine, unspecified formulation Test Case Fixed
RXA.5.3 Name of Coding System CVX Test Case Fixed
RXA.5.5 Alternate Text
RXA.5.6 Name of Alternate Coding System
RXA.6 Administered Amount 999 Test Case Fixed
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier
RXA.9.2 Text
RXA.9.3 Name of Coding System
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number
RXA.16 Substance Expiration Date
RXA.16.1 Time
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier
RXA.17.2 Text
RXA.17.3 Name of Coding System
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status NA Test Case Fixed
RXA.21 Action Code - RXA A

RXA - 3
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20150715
RXA.5 Administered Code
RXA.5.1 Identifier 107 Test Case Fixed
RXA.5.2 Text DTaP, unspecified formulation Test Case Fixed
RXA.5.3 Name of Coding System CVX Test Case Fixed
RXA.5.5 Alternate Text
RXA.5.6 Name of Alternate Coding System
RXA.6 Administered Amount 999 Test Case Fixed
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier
RXA.9.2 Text
RXA.9.3 Name of Coding System
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number
RXA.16 Substance Expiration Date
RXA.16.1 Time
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier
RXA.17.2 Text
RXA.17.3 Name of Coding System
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status NA Test Case Fixed
RXA.21 Action Code - RXA A

RXA - 4
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20150715
RXA.5 Administered Code
RXA.5.1 Identifier 08 Test Case Fixed
RXA.5.2 Text Hib Test Case Fixed
RXA.5.3 Name of Coding System CVX Test Case Fixed
RXA.5.5 Alternate Text
RXA.5.6 Name of Alternate Coding System
RXA.6 Administered Amount 999 Test Case Fixed
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier
RXA.9.2 Text
RXA.9.3 Name of Coding System
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number
RXA.16 Substance Expiration Date
RXA.16.1 Time
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier
RXA.17.2 Text
RXA.17.3 Name of Coding System
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status NA Test Case Fixed
RXA.21 Action Code - RXA A

RXA - 5
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20150715
RXA.5 Administered Code
RXA.5.1 Identifier 152 Test Case Fixed
RXA.5.2 Text Pneumococcal Conjugate, unspecified formulation Test Case Fixed
RXA.5.3 Name of Coding System CVX Test Case Fixed
RXA.5.5 Alternate Text
RXA.5.6 Name of Alternate Coding System
RXA.6 Administered Amount 999 Test Case Fixed
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier
RXA.9.2 Text
RXA.9.3 Name of Coding System
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number
RXA.16 Substance Expiration Date
RXA.16.1 Time
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier
RXA.17.2 Text
RXA.17.3 Name of Coding System
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status NA Test Case Fixed
RXA.21 Action Code - RXA A

RXA - 6
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20150715
RXA.5 Administered Code
RXA.5.1 Identifier 122 Test Case Fixed
RXA.5.2 Text rotavirus, unspecified formulation Test Case Fixed
RXA.5.3 Name of Coding System CVX Test Case Fixed
RXA.5.5 Alternate Text
RXA.5.6 Name of Alternate Coding System
RXA.6 Administered Amount 999 Test Case Fixed
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier
RXA.9.2 Text
RXA.9.3 Name of Coding System
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number
RXA.16 Substance Expiration Date
RXA.16.1 Time
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier
RXA.17.2 Text
RXA.17.3 Name of Coding System
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status NA Test Case Fixed
RXA.21 Action Code - RXA A

RXR
Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

OBX[*]
OBX - 1
Location Data Element Data Categorization
OBX.1 Set ID - OBX 1
OBX.2 Value Type CE
OBX.3 Observation Identifier
OBX.3.1 Identifier 30945-0 Test Case Fixed
OBX.3.2 Text Vaccination contraindication Test Case Fixed
OBX.3.3 Name of Coding System LN Test Case Fixed
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 2
Location Data Element Data Categorization
OBX.1 Set ID - OBX 2
OBX.2 Value Type TS
OBX.3 Observation Identifier
OBX.3.1 Identifier 30946-8 Test Case Fixed
OBX.3.2 Text Vaccination contraindication/precaution effective date Test Case Fixed
OBX.3.3 Name of Coding System LN Test Case Fixed
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.5.1 Time 20150715
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 3
Location Data Element Data Categorization
OBX.1 Set ID - OBX 3
OBX.2 Value Type TS
OBX.3 Observation Identifier
OBX.3.1 Identifier 30944-3 Test Case Fixed
OBX.3.2 Text Vaccination temporary contraindication/precaution expiration date Test Case Fixed
OBX.3.3 Name of Coding System LN Test Case Fixed
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.5.1 Time 20150815
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 4
Location Data Element Data Categorization
OBX.1 Set ID - OBX 1
OBX.2 Value Type CE
OBX.3 Observation Identifier
OBX.3.1 Identifier 30945-0 Test Case Fixed
OBX.3.2 Text Vaccination contraindication Test Case Fixed
OBX.3.3 Name of Coding System LN Test Case Fixed
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 5
Location Data Element Data Categorization
OBX.1 Set ID - OBX 2
OBX.2 Value Type TS
OBX.3 Observation Identifier
OBX.3.1 Identifier 30946-8 Test Case Fixed
OBX.3.2 Text Vaccination contraindication/precaution effective date Test Case Fixed
OBX.3.3 Name of Coding System LN Test Case Fixed
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.5.1 Time 20150715
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 6
Location Data Element Data Categorization
OBX.1 Set ID - OBX 3
OBX.2 Value Type TS
OBX.3 Observation Identifier
OBX.3.1 Identifier 30944-3 Test Case Fixed
OBX.3.2 Text Vaccination temporary contraindication/precaution expiration date Test Case Fixed
OBX.3.3 Name of Coding System LN Test Case Fixed
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.5.1 Time 20150815
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 7
Location Data Element Data Categorization
OBX.1 Set ID - OBX 1
OBX.2 Value Type CE
OBX.3 Observation Identifier
OBX.3.1 Identifier 30945-0 Test Case Fixed
OBX.3.2 Text Vaccination contraindication Test Case Fixed
OBX.3.3 Name of Coding System LN Test Case Fixed
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 8
Location Data Element Data Categorization
OBX.1 Set ID - OBX 2
OBX.2 Value Type TS
OBX.3 Observation Identifier
OBX.3.1 Identifier 30946-8 Test Case Fixed
OBX.3.2 Text Vaccination contraindication/precaution effective date Test Case Fixed
OBX.3.3 Name of Coding System LN Test Case Fixed
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.5.1 Time 20150715
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 9
Location Data Element Data Categorization
OBX.1 Set ID - OBX 3
OBX.2 Value Type TS
OBX.3 Observation Identifier
OBX.3.1 Identifier 30944-3 Test Case Fixed
OBX.3.2 Text Vaccination temporary contraindication/precaution expiration date Test Case Fixed
OBX.3.3 Name of Coding System LN Test Case Fixed
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.5.1 Time 20150815
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 10
Location Data Element Data Categorization
OBX.1 Set ID - OBX 1
OBX.2 Value Type CE
OBX.3 Observation Identifier
OBX.3.1 Identifier 30945-0 Test Case Fixed
OBX.3.2 Text Vaccination contraindication Test Case Fixed
OBX.3.3 Name of Coding System LN Test Case Fixed
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 11
Location Data Element Data Categorization
OBX.1 Set ID - OBX 2
OBX.2 Value Type TS
OBX.3 Observation Identifier
OBX.3.1 Identifier 30946-8 Test Case Fixed
OBX.3.2 Text Vaccination contraindication/precaution effective date Test Case Fixed
OBX.3.3 Name of Coding System LN Test Case Fixed
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.5.1 Time 20150715
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 12
Location Data Element Data Categorization
OBX.1 Set ID - OBX 3
OBX.2 Value Type TS
OBX.3 Observation Identifier
OBX.3.1 Identifier 30944-3 Test Case Fixed
OBX.3.2 Text Vaccination temporary contraindication/precaution expiration date Test Case Fixed
OBX.3.3 Name of Coding System LN Test Case Fixed
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.5.1 Time 20150815
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 13
Location Data Element Data Categorization
OBX.1 Set ID - OBX 1
OBX.2 Value Type CE
OBX.3 Observation Identifier
OBX.3.1 Identifier 30945-0 Test Case Fixed
OBX.3.2 Text Vaccination contraindication Test Case Fixed
OBX.3.3 Name of Coding System LN Test Case Fixed
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 14
Location Data Element Data Categorization
OBX.1 Set ID - OBX 2
OBX.2 Value Type TS
OBX.3 Observation Identifier
OBX.3.1 Identifier 30946-8 Test Case Fixed
OBX.3.2 Text Vaccination contraindication/precaution effective date Test Case Fixed
OBX.3.3 Name of Coding System LN Test Case Fixed
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.5.1 Time 20150715
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 15
Location Data Element Data Categorization
OBX.1 Set ID - OBX 3
OBX.2 Value Type TS
OBX.3 Observation Identifier
OBX.3.1 Identifier 30944-3 Test Case Fixed
OBX.3.2 Text Vaccination temporary contraindication/precaution expiration date Test Case Fixed
OBX.3.3 Name of Coding System LN Test Case Fixed
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.5.1 Time 20150815
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

Location Data Element Data Categorization
MSH.1 Field Separator |
MSH.2 Encoding Characters ^~\&
MSH.3 Sending Application
MSH.3.1 Namespace ID Test EHR Application
MSH.3.2 Universal ID
MSH.3.3 Universal ID Type
MSH.4 Sending Facility
MSH.4.1 Namespace ID X68
MSH.4.2 Universal ID
MSH.4.3 Universal ID Type
MSH.5 Receiving Application
MSH.5.1 Namespace ID
MSH.5.2 Universal ID
MSH.5.3 Universal ID Type
MSH.6 Receiving Facility
MSH.6.1 Namespace ID NIST Test Iz Reg
MSH.6.2 Universal ID
MSH.6.3 Universal ID Type
MSH.7 Date/Time Of Message
MSH.7.1 Time 20120701082240-0500
MSH.9 Message Type
MSH.9.1 Message Code VXU
MSH.9.2 Trigger Event V04
MSH.9.3 Message Structure VXU_V04
MSH.10 Message Control ID NIST-IZ-001.00
MSH.11 Processing ID
MSH.11.1 Processing ID P
MSH.12 Version ID
MSH.12.1 Version ID 2.5.1
MSH.15 Accept Acknowledgment Type ER
MSH.16 Application Acknowledgment Type AL
MSH.21 Message Profile Identifier
MSH.21.1 Entity Identifier Z22
MSH.21.2 Namespace ID CDCPHINVS
MSH.21.3 Universal ID
MSH.21.4 Universal ID Type
MSH.22 Sending Responsible Organization
MSH.22.1 Organization Name
MSH.22.6 Assigning Authority
MSH.22.6.1 Namespace ID
MSH.22.6.2 Universal ID
MSH.22.6.3 Universal ID Type
MSH.22.7 Identifier Type Code
MSH.22.10 Organization Identifier
MSH.23 Receiving Responsible Organization
MSH.23.1 Organization Name
MSH.23.6 Assigning Authority
MSH.23.6.1 Namespace ID
MSH.23.6.2 Universal ID
MSH.23.6.3 Universal ID Type
MSH.23.7 Identifier Type Code
MSH.23.10 Organization Identifier

Location Data Element Data Categorization
PID.1 Set ID - PID 1
PID.3 Patient Identifier List
PID.3.1 ID Number 123456
PID.3.3 Check Digit Scheme
PID.3.4 Assigning Authority
PID.3.4.1 Namespace ID MYEHR
PID.3.4.2 Universal ID
PID.3.4.3 Universal ID Type
PID.3.5 Identifier Type Code MR
PID.3 Patient Identifier List
PID.3.1 ID Number 987633
PID.3.3 Check Digit Scheme
PID.3.4 Assigning Authority
PID.3.4.1 Namespace ID MYIIS
PID.3.4.2 Universal ID
PID.3.4.3 Universal ID Type
PID.3.5 Identifier Type Code SR
PID.5 Patient Name
PID.5.1 Family Name
PID.5.1.1 Surname Morales
PID.5.1.2 Own Surname Prefix
PID.5.1.3 Own Surname
PID.5.1.4 Surname Prefix From Partner/Spouse
PID.5.1.5 Surname From Partner/Spouse
PID.5.2 Given Name Mariela Test Case Fixed
PID.5.3 Second and Further Given Names or Initials Thereof Gonzales Test Case Fixed
PID.5.7 Name Type Code L Test Case Fixed
PID.6 Mother's Maiden Name
PID.6.1 Family Name
PID.6.1.1 Surname Gonzales Test Case Fixed
PID.6.1.2 Own Surname Prefix
PID.6.1.3 Own Surname
PID.6.1.4 Surname Prefix From Partner/Spouse
PID.6.1.5 Surname From Partner/Spouse
PID.6.7 Name Type Code M Test Case Fixed
PID.7 Date/Time of Birth
PID.7.1 Time 201503301115 Test Case Fixed
PID.8 Administrative Sex F Test Case Fixed
PID.10 Race
PID.10.1 Identifier 2131-1 Test Case Fixed
PID.10.2 Text Other Race Test Case Fixed
PID.10.3 Name of Coding System HL70005 Test Case Fixed
PID.10.5 Alternate Text
PID.10.6 Name of Alternate Coding System
PID.11 Patient Address
PID.11.1 Street Address
PID.11.1.1 Street or Mailing Address 3321 Standish Way Test Case Fixed
PID.11.1.2 Street Name
PID.11.1.3 Dwelling Number
PID.11.2 Other Designation
PID.11.3 City Stamford Test Case Fixed
PID.11.4 State or Province CT Test Case Fixed
PID.11.5 Zip or Postal Code 06903 Test Case Fixed
PID.11.6 Country USA Test Case Fixed
PID.11.7 Address Type L Test Case Fixed
PID.11 Patient Address
PID.11.1 Street Address
PID.11.1.1 Street or Mailing Address 325 Shorline Drive
PID.11.1.2 Street Name
PID.11.1.3 Dwelling Number
PID.11.2 Other Designation
PID.11.3 City Stamford
PID.11.4 State or Province CT Test Case Fixed
PID.11.5 Zip or Postal Code 06901
PID.11.6 Country
PID.11.7 Address Type BDL Test Case Fixed
PID.13 Phone Number - Home
PID.13.2 Telecommunication Use Code PRN Test Case Fixed
PID.13.3 Telecommunication Equipment Type PH Test Case Fixed
PID.13.4 Email Address
PID.13.6 Area/City Code 203 Test Case Fixed
PID.13.7 Local Number 5551214 Test Case Fixed
PID.22 Ethnic Group
PID.22.1 Identifier 2135-2 Test Case Fixed
PID.22.2 Text Hispanic or Latino Test Case Fixed
PID.22.3 Name of Coding System CDCREC Test Case Fixed
PID.22.5 Alternate Text
PID.22.6 Name of Alternate Coding System
PID.24 Multiple Birth Indicator
PID.25 Birth Order
PID.29 Patient Death Date and Time
PID.29.1 Time
PID.30 Patient Death Indicator

Location Data Element Data Categorization
PD1.11 Publicity Code
PD1.11.1 Identifier 02
PD1.11.2 Text Reminder/Recall - any method
PD1.11.3 Name of Coding System HL70215
PD1.11.5 Alternate Text
PD1.11.6 Name of Alternate Coding System
PD1.12 Protection Indicator
PD1.13 Protection Indicator Effective Date
PD1.16 Immunization Registry Status A
PD1.17 Immunization Registry Status Effective Date 20120701
PD1.18 Publicity Code Effective Date 20120701

Location Data Element Data Categorization
NK1.1 Set ID - NK1 1
NK1.2 Name
NK1.2.1 Family Name
NK1.2.1.1 Surname Morales Test Case Fixed
NK1.2.1.2 Own Surname Prefix
NK1.2.1.3 Own Surname
NK1.2.1.4 Surname Prefix From Partner/Spouse
NK1.2.1.5 Surname From Partner/Spouse
NK1.2.2 Given Name Joanna Test Case Fixed
NK1.2.3 Second and Further Given Names or Initials Thereof Gonzales Test Case Fixed
NK1.2.7 Name Type Code L Test Case Fixed
NK1.3 Relationship
NK1.3.1 Identifier MTH Test Case Fixed
NK1.3.2 Text Mother Test Case Fixed
NK1.3.3 Name of Coding System HL70063
NK1.3.5 Alternate Text
NK1.3.6 Name of Alternate Coding System
NK1.4 Address
NK1.4.1 Street Address
NK1.4.1.1 Street or Mailing Address 4623 Standish Way Test Case Fixed
NK1.4.1.2 Street Name
NK1.4.1.3 Dwelling Number
NK1.4.2 Other Designation
NK1.4.3 City Stamford Test Case Fixed
NK1.4.4 State or Province CT Test Case Fixed
NK1.4.5 Zip or Postal Code 06903 Test Case Fixed
NK1.4.6 Country
NK1.4.7 Address Type L Test Case Fixed
NK1.5 Phone Number
NK1.5.2 Telecommunication Use Code PRN Test Case Fixed
NK1.5.3 Telecommunication Equipment Type PH Test Case Fixed
NK1.5.4 Email Address
NK1.5.6 Area/City Code 203 Test Case Fixed
NK1.5.7 Local Number 5551213 Test Case Fixed

ORC - 1
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 197027
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Sirtis Test Case Fixed
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name Lisa
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Carter
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Jane
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier SH
ORC.17.2 Text Shoreline Hospital
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 2
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 9999
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Molina Test Case Fixed
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name Sandra Test Case Fixed
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Smith Test Case Fixed
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Frank Test Case Fixed
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L Test Case Fixed
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier SP
ORC.17.2 Text Shoreline Pediatrics Test Case Fixed
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 3
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 9999
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Molina Test Case Fixed
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name Sandra Test Case Fixed
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Smith Test Case Fixed
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Frank Test Case Fixed
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier SP
ORC.17.2 Text Shoreline Pediatrics Test Case Fixed
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 4
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 9999
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Molina Test Case Fixed
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name Sandra Test Case Fixed
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Smith Test Case Fixed
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Frank Test Case Fixed
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L Test Case Fixed
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier SP
ORC.17.2 Text Shoreline Pediatrics Test Case Fixed
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 5
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 9999
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Molina Test Case Fixed
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name Sandra Test Case Fixed
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Smith Test Case Fixed
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Frank Test Case Fixed
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L Test Case Fixed
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier SP
ORC.17.2 Text Shoreline Pediatrics Test Case Fixed
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

ORC - 6
Location Data Element Data Categorization
ORC.1 Order Control RE
ORC.2 Placer Order Number
ORC.2.1 Entity Identifier
ORC.2.2 Namespace ID
ORC.2.3 Universal ID
ORC.2.4 Universal ID Type
ORC.3 Filler Order Number
ORC.3.1 Entity Identifier 9999
ORC.3.2 Namespace ID DCS
ORC.3.3 Universal ID
ORC.3.4 Universal ID Type
ORC.10 Entered By
ORC.10.1 ID Number
ORC.10.2 Family Name
ORC.10.2.1 Surname Molina Test Case Fixed
ORC.10.2.2 Own Surname Prefix
ORC.10.2.3 Own Surname
ORC.10.2.4 Surname Prefix From Partner/Spouse
ORC.10.2.5 Surname From Partner/Spouse
ORC.10.3 Given Name Sandra Test Case Fixed
ORC.10.4 Second and Further Given Names or Initials Thereof
ORC.10.9 Assigning Authority
ORC.10.9.1 Namespace ID
ORC.10.9.2 Universal ID
ORC.10.9.3 Universal ID Type
ORC.10.10 Name Type Code
ORC.10.12 Check Digit Scheme
ORC.10.13 Identifier Type Code
ORC.12 Ordering Provider
ORC.12.1 ID Number
ORC.12.2 Family Name
ORC.12.2.1 Surname Smith Test Case Fixed
ORC.12.2.2 Own Surname Prefix
ORC.12.2.3 Own Surname
ORC.12.2.4 Surname Prefix From Partner/Spouse
ORC.12.2.5 Surname From Partner/Spouse
ORC.12.3 Given Name Frank Test Case Fixed
ORC.12.4 Second and Further Given Names or Initials Thereof
ORC.12.9 Assigning Authority
ORC.12.9.1 Namespace ID
ORC.12.9.2 Universal ID
ORC.12.9.3 Universal ID Type
ORC.12.10 Name Type Code L
ORC.12.12 Check Digit Scheme
ORC.12.13 Identifier Type Code
ORC.17 Entering Organization
ORC.17.1 Identifier SP
ORC.17.2 Text Shoreline Pediatrics Test Case Fixed
ORC.17.3 Name of Coding System HL70362
ORC.17.5 Alternate Text
ORC.17.6 Name of Alternate Coding System

RXA - 1
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20091123
RXA.5 Administered Code
RXA.5.1 Identifier 08
RXA.5.2 Text hepatitis B vaccine, pediatric or pediatric/adolescent dosage
RXA.5.3 Name of Coding System CVX
RXA.5.5 Alternate Text ENGERIX-B
RXA.5.6 Name of Alternate Coding System NDC
RXA.6 Administered Amount 999
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier 08
RXA.9.2 Text Historical information - from public agency
RXA.9.3 Name of Coding System NIP001
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname Sirtis
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name Lisa
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID DCS_DC
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number 6332FK33
RXA.16 Substance Expiration Date
RXA.16.1 Time 20101214
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier SKB
RXA.17.2 Text GlaxoSmithKline Biologicals SA
RXA.17.3 Name of Coding System MVX
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status CP
RXA.21 Action Code - RXA A

RXA - 2
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20150715
RXA.5 Administered Code
RXA.5.1 Identifier 45 Test Case Fixed
RXA.5.2 Text hepatitis B vaccine, unspecified formulation Test Case Fixed
RXA.5.3 Name of Coding System CVX Test Case Fixed
RXA.5.5 Alternate Text
RXA.5.6 Name of Alternate Coding System
RXA.6 Administered Amount 999 Test Case Fixed
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier
RXA.9.2 Text
RXA.9.3 Name of Coding System
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number
RXA.16 Substance Expiration Date
RXA.16.1 Time
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier
RXA.17.2 Text
RXA.17.3 Name of Coding System
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status NA Test Case Fixed
RXA.21 Action Code - RXA A

RXA - 3
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20150715
RXA.5 Administered Code
RXA.5.1 Identifier 107 Test Case Fixed
RXA.5.2 Text DTaP, unspecified formulation Test Case Fixed
RXA.5.3 Name of Coding System CVX Test Case Fixed
RXA.5.5 Alternate Text
RXA.5.6 Name of Alternate Coding System
RXA.6 Administered Amount 999 Test Case Fixed
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier
RXA.9.2 Text
RXA.9.3 Name of Coding System
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number
RXA.16 Substance Expiration Date
RXA.16.1 Time
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier
RXA.17.2 Text
RXA.17.3 Name of Coding System
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status NA Test Case Fixed
RXA.21 Action Code - RXA A

RXA - 4
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20150715
RXA.5 Administered Code
RXA.5.1 Identifier 08 Test Case Fixed
RXA.5.2 Text Hib Test Case Fixed
RXA.5.3 Name of Coding System CVX Test Case Fixed
RXA.5.5 Alternate Text
RXA.5.6 Name of Alternate Coding System
RXA.6 Administered Amount 999 Test Case Fixed
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier
RXA.9.2 Text
RXA.9.3 Name of Coding System
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number
RXA.16 Substance Expiration Date
RXA.16.1 Time
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier
RXA.17.2 Text
RXA.17.3 Name of Coding System
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status NA Test Case Fixed
RXA.21 Action Code - RXA A

RXA - 5
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20150715
RXA.5 Administered Code
RXA.5.1 Identifier 152 Test Case Fixed
RXA.5.2 Text Pneumococcal Conjugate, unspecified formulation Test Case Fixed
RXA.5.3 Name of Coding System CVX Test Case Fixed
RXA.5.5 Alternate Text
RXA.5.6 Name of Alternate Coding System
RXA.6 Administered Amount 999 Test Case Fixed
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier
RXA.9.2 Text
RXA.9.3 Name of Coding System
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number
RXA.16 Substance Expiration Date
RXA.16.1 Time
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier
RXA.17.2 Text
RXA.17.3 Name of Coding System
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status NA Test Case Fixed
RXA.21 Action Code - RXA A

RXA - 6
Location Data Element Data Categorization
RXA.1 Give Sub-ID Counter 0
RXA.2 Administration Sub-ID Counter 1
RXA.3 Date/Time Start of Administration
RXA.3.1 Time 20150715
RXA.5 Administered Code
RXA.5.1 Identifier 122 Test Case Fixed
RXA.5.2 Text rotavirus, unspecified formulation Test Case Fixed
RXA.5.3 Name of Coding System CVX Test Case Fixed
RXA.5.5 Alternate Text
RXA.5.6 Name of Alternate Coding System
RXA.6 Administered Amount 999 Test Case Fixed
RXA.7 Administered Units
RXA.7.1 Identifier
RXA.7.2 Text
RXA.7.3 Name of Coding System
RXA.7.5 Alternate Text
RXA.7.6 Name of Alternate Coding System
RXA.9 Administration Notes
RXA.9.1 Identifier
RXA.9.2 Text
RXA.9.3 Name of Coding System
RXA.9.5 Alternate Text
RXA.9.6 Name of Alternate Coding System
RXA.10 Administering Provider
RXA.10.1 ID Number
RXA.10.2 Family Name
RXA.10.2.1 Surname
RXA.10.2.2 Own Surname Prefix
RXA.10.2.3 Own Surname
RXA.10.2.4 Surname Prefix From Partner/Spouse
RXA.10.2.5 Surname From Partner/Spouse
RXA.10.3 Given Name
RXA.10.4 Second and Further Given Names or Initials Thereof
RXA.10.9 Assigning Authority
RXA.10.9.1 Namespace ID
RXA.10.9.2 Universal ID
RXA.10.9.3 Universal ID Type
RXA.10.10 Name Type Code
RXA.10.12 Check Digit Scheme
RXA.10.13 Identifier Type Code
RXA.11 Administered-at Location
RXA.11.4 Facility
RXA.11.4.1 Namespace ID
RXA.11.4.2 Universal ID
RXA.11.4.3 Universal ID Type
RXA.15 Substance Lot Number
RXA.16 Substance Expiration Date
RXA.16.1 Time
RXA.17 Substance Manufacturer Name
RXA.17.1 Identifier
RXA.17.2 Text
RXA.17.3 Name of Coding System
RXA.17.5 Alternate Text
RXA.17.6 Name of Alternate Coding System
RXA.18 Substance/Treatment Refusal Reason
RXA.18.1 Identifier
RXA.18.2 Text
RXA.18.3 Name of Coding System
RXA.18.5 Alternate Text
RXA.18.6 Name of Alternate Coding System
RXA.20 Completion Status NA Test Case Fixed
RXA.21 Action Code - RXA A

Location Data Element Data Categorization
RXR.1 Route
RXR.1.1 Identifier C28161
RXR.1.2 Text IM
RXR.1.3 Name of Coding System NCIT
RXR.1.5 Alternate Text IM
RXR.1.6 Name of Alternate Coding System HL70162
RXR.2 Administration Site
RXR.2.1 Identifier LT
RXR.2.2 Text Left Thigh
RXR.2.3 Name of Coding System HL70163
RXR.2.5 Alternate Text
RXR.2.6 Name of Alternate Coding System

OBX - 1
Location Data Element Data Categorization
OBX.1 Set ID - OBX 1
OBX.2 Value Type CE
OBX.3 Observation Identifier
OBX.3.1 Identifier 30945-0 Test Case Fixed
OBX.3.2 Text Vaccination contraindication Test Case Fixed
OBX.3.3 Name of Coding System LN Test Case Fixed
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 2
Location Data Element Data Categorization
OBX.1 Set ID - OBX 2
OBX.2 Value Type TS
OBX.3 Observation Identifier
OBX.3.1 Identifier 30946-8 Test Case Fixed
OBX.3.2 Text Vaccination contraindication/precaution effective date Test Case Fixed
OBX.3.3 Name of Coding System LN Test Case Fixed
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.5.1 Time 20150715
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 3
Location Data Element Data Categorization
OBX.1 Set ID - OBX 3
OBX.2 Value Type TS
OBX.3 Observation Identifier
OBX.3.1 Identifier 30944-3 Test Case Fixed
OBX.3.2 Text Vaccination temporary contraindication/precaution expiration date Test Case Fixed
OBX.3.3 Name of Coding System LN Test Case Fixed
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.5.1 Time 20150815
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 4
Location Data Element Data Categorization
OBX.1 Set ID - OBX 1
OBX.2 Value Type CE
OBX.3 Observation Identifier
OBX.3.1 Identifier 30945-0 Test Case Fixed
OBX.3.2 Text Vaccination contraindication Test Case Fixed
OBX.3.3 Name of Coding System LN Test Case Fixed
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 5
Location Data Element Data Categorization
OBX.1 Set ID - OBX 2
OBX.2 Value Type TS
OBX.3 Observation Identifier
OBX.3.1 Identifier 30946-8 Test Case Fixed
OBX.3.2 Text Vaccination contraindication/precaution effective date Test Case Fixed
OBX.3.3 Name of Coding System LN Test Case Fixed
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.5.1 Time 20150715
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 6
Location Data Element Data Categorization
OBX.1 Set ID - OBX 3
OBX.2 Value Type TS
OBX.3 Observation Identifier
OBX.3.1 Identifier 30944-3 Test Case Fixed
OBX.3.2 Text Vaccination temporary contraindication/precaution expiration date Test Case Fixed
OBX.3.3 Name of Coding System LN Test Case Fixed
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.5.1 Time 20150815
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 7
Location Data Element Data Categorization
OBX.1 Set ID - OBX 1
OBX.2 Value Type CE
OBX.3 Observation Identifier
OBX.3.1 Identifier 30945-0 Test Case Fixed
OBX.3.2 Text Vaccination contraindication Test Case Fixed
OBX.3.3 Name of Coding System LN Test Case Fixed
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 8
Location Data Element Data Categorization
OBX.1 Set ID - OBX 2
OBX.2 Value Type TS
OBX.3 Observation Identifier
OBX.3.1 Identifier 30946-8 Test Case Fixed
OBX.3.2 Text Vaccination contraindication/precaution effective date Test Case Fixed
OBX.3.3 Name of Coding System LN Test Case Fixed
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.5.1 Time 20150715
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 9
Location Data Element Data Categorization
OBX.1 Set ID - OBX 3
OBX.2 Value Type TS
OBX.3 Observation Identifier
OBX.3.1 Identifier 30944-3 Test Case Fixed
OBX.3.2 Text Vaccination temporary contraindication/precaution expiration date Test Case Fixed
OBX.3.3 Name of Coding System LN Test Case Fixed
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.5.1 Time 20150815
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 10
Location Data Element Data Categorization
OBX.1 Set ID - OBX 1
OBX.2 Value Type CE
OBX.3 Observation Identifier
OBX.3.1 Identifier 30945-0 Test Case Fixed
OBX.3.2 Text Vaccination contraindication Test Case Fixed
OBX.3.3 Name of Coding System LN Test Case Fixed
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 11
Location Data Element Data Categorization
OBX.1 Set ID - OBX 2
OBX.2 Value Type TS
OBX.3 Observation Identifier
OBX.3.1 Identifier 30946-8 Test Case Fixed
OBX.3.2 Text Vaccination contraindication/precaution effective date Test Case Fixed
OBX.3.3 Name of Coding System LN Test Case Fixed
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.5.1 Time 20150715
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 12
Location Data Element Data Categorization
OBX.1 Set ID - OBX 3
OBX.2 Value Type TS
OBX.3 Observation Identifier
OBX.3.1 Identifier 30944-3 Test Case Fixed
OBX.3.2 Text Vaccination temporary contraindication/precaution expiration date Test Case Fixed
OBX.3.3 Name of Coding System LN Test Case Fixed
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.5.1 Time 20150815
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 13
Location Data Element Data Categorization
OBX.1 Set ID - OBX 1
OBX.2 Value Type CE
OBX.3 Observation Identifier
OBX.3.1 Identifier 30945-0 Test Case Fixed
OBX.3.2 Text Vaccination contraindication Test Case Fixed
OBX.3.3 Name of Coding System LN Test Case Fixed
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 14
Location Data Element Data Categorization
OBX.1 Set ID - OBX 2
OBX.2 Value Type TS
OBX.3 Observation Identifier
OBX.3.1 Identifier 30946-8 Test Case Fixed
OBX.3.2 Text Vaccination contraindication/precaution effective date Test Case Fixed
OBX.3.3 Name of Coding System LN Test Case Fixed
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.5.1 Time 20150715
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

OBX - 15
Location Data Element Data Categorization
OBX.1 Set ID - OBX 3
OBX.2 Value Type TS
OBX.3 Observation Identifier
OBX.3.1 Identifier 30944-3 Test Case Fixed
OBX.3.2 Text Vaccination temporary contraindication/precaution expiration date Test Case Fixed
OBX.3.3 Name of Coding System LN Test Case Fixed
OBX.3.5 Alternate Text
OBX.3.6 Name of Alternate Coding System
OBX.4 Observation Sub-ID 1
OBX.5 Observation Value
OBX.5.1 Time 20150815
OBX.6 Units
OBX.6.1 Identifier
OBX.6.2 Text
OBX.6.3 Name of Coding System
OBX.6.5 Alternate Text
OBX.6.6 Name of Alternate Coding System
OBX.11 Observation Result Status F
OBX.14 Date/Time of the Observation
OBX.14.1 Time 20150715
OBX.17 Observation Method
OBX.17.1 Identifier
OBX.17.2 Text
OBX.17.3 Name of Coding System
OBX.17.5 Alternate Text
OBX.17.6 Name of Alternate Coding System

Test Data Specification

Patient Information
Element Data
Patient Name Mariela Gonzales Morales
Mother's Maiden Name Joanna Gonzales
ID Number 123456 987633
Date/Time of Birth 03/30/2015
Administrative Sex Female
Patient Address 3321 Standish Way Stamford CT 06903 USA
Patient Address 1 325 Shorline Drive Stamford CT 06901
Local Number (203)555-1214
Race Other Race
Ethnic Group Hispanic or Latino
Birth Order
Immunization Registry Information
Element Data
Immunization Registry Status A
Immunization Registry Status Effective Date 07/01/2012
Publicity Code Reminder/Recall - any method
Publicity Code Effective Date 07/01/2012
Protection Indicator
Protection Indicator Effective Date
Guardian or Responsible Party
Element Data
Name Joanna Gonzales Morales
Relationship Mother
Address 4623 Standish Way Stamford CT 06903
Phone Number (203)555-1213

Vaccine Administration Information[*]
Vaccine Administration Information - 1
Element Data
Administered Code hepatitis B vaccine, pediatric or pediatric/adolescent dosage
Date/Time Start of Administration 11/23/2009
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider Lisa Sirtis
Substance Lot Number 6332FK33
Substance Expiration Date 12/14/2010
Substance Manufacturer Name GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Thigh
Entering Organization Shoreline Hospital
Entered By Lisa Sirtis
Ordered By Jane Carter

Vaccine Administration Information - 2
Element Data
Administered Code hepatitis B vaccine, unspecified formulation
Date/Time Start of Administration 07/15/2015
Administered Amount 999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason
Completion Status NA
Action Code Add
Route
Administration Site
Entering Organization Shoreline Pediatrics
Entered By Sandra Molina
Ordered By Frank Smith

Element Data
Vaccination contraindication current fever with moderate-to-severe illness
Vaccination contraindication/precaution effective date 07/15/2015
Vaccination temporary contraindication/precaution expiration date 08/15/2015

Vaccine Administration Information - 3
Element Data
Administered Code DTaP, unspecified formulation
Date/Time Start of Administration 07/15/2015
Administered Amount 999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason
Completion Status NA
Action Code Add
Route
Administration Site
Entering Organization Shoreline Pediatrics
Entered By Sandra Molina
Ordered By Frank Smith

Element Data
Vaccination contraindication current fever with moderate-to-severe illness
Vaccination contraindication/precaution effective date 07/15/2015
Vaccination temporary contraindication/precaution expiration date 08/15/2015

Vaccine Administration Information - 4
Element Data
Administered Code Hib
Date/Time Start of Administration 07/15/2015
Administered Amount 999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason
Completion Status NA
Action Code Add
Route
Administration Site
Entering Organization Shoreline Pediatrics
Entered By Sandra Molina
Ordered By Frank Smith

Element Data
Vaccination contraindication current fever with moderate-to-severe illness
Vaccination contraindication/precaution effective date 07/15/2015
Vaccination temporary contraindication/precaution expiration date 08/15/2015

Vaccine Administration Information - 5
Element Data
Administered Code Pneumococcal Conjugate, unspecified formulation
Date/Time Start of Administration 07/15/2015
Administered Amount 999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason
Completion Status NA
Action Code Add
Route
Administration Site
Entering Organization Shoreline Pediatrics
Entered By Sandra Molina
Ordered By Frank Smith

Element Data
Vaccination contraindication current fever with moderate-to-severe illness
Vaccination contraindication/precaution effective date 07/15/2015
Vaccination temporary contraindication/precaution expiration date 08/15/2015

Vaccine Administration Information - 6
Element Data
Administered Code rotavirus, unspecified formulation
Date/Time Start of Administration 07/15/2015
Administered Amount 999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason
Completion Status NA
Action Code Add
Route
Administration Site
Entering Organization Shoreline Pediatrics
Entered By Sandra Molina
Ordered By Frank Smith

Element Data
Vaccination contraindication current fever with moderate-to-severe illness
Vaccination contraindication/precaution effective date 07/15/2015
Vaccination temporary contraindication/precaution expiration date 08/15/2015
Element Data
Patient Name Mariela Gonzales Morales
Mother's Maiden Name Joanna Gonzales
ID Number 123456 987633
Date/Time of Birth 03/30/2015
Administrative Sex Female
Patient Address 3321 Standish Way Stamford CT 06903 USA
Patient Address 1 325 Shorline Drive Stamford CT 06901
Local Number (203)555-1214
Race Other Race
Ethnic Group Hispanic or Latino
Birth Order
Element Data
Immunization Registry Status A
Immunization Registry Status Effective Date 07/01/2012
Publicity Code Reminder/Recall - any method
Publicity Code Effective Date 07/01/2012
Protection Indicator
Protection Indicator Effective Date
Element Data
Name Joanna Gonzales Morales
Relationship Mother
Address 4623 Standish Way Stamford CT 06903
Phone Number (203)555-1213
Vaccine Administration Information - 1
Element Data
Administered Code hepatitis B vaccine, pediatric or pediatric/adolescent dosage
Date/Time Start of Administration 11/23/2009
Administered Amount 999
Administered Units
Administration Notes Historical information - from public agency
Administering Provider Lisa Sirtis
Substance Lot Number 6332FK33
Substance Expiration Date 12/14/2010
Substance Manufacturer Name GlaxoSmithKline Biologicals SA
Substance/Treatment Refusal Reason
Completion Status CP
Action Code Add
Route IM
Administration Site Left Thigh
Entering Organization Shoreline Hospital
Entered By Lisa Sirtis
Ordered By Jane Carter

 Vaccine Administration Information - 2
Element Data
Administered Code hepatitis B vaccine, unspecified formulation
Date/Time Start of Administration 07/15/2015
Administered Amount 999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason
Completion Status NA
Action Code Add
Route
Administration Site
Entering Organization Shoreline Pediatrics
Entered By Sandra Molina
Ordered By Frank Smith

Element Data
Vaccination contraindication current fever with moderate-to-severe illness
Vaccination contraindication/precaution effective date 07/15/2015
Vaccination temporary contraindication/precaution expiration date 08/15/2015

 Vaccine Administration Information - 3
Element Data
Administered Code DTaP, unspecified formulation
Date/Time Start of Administration 07/15/2015
Administered Amount 999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason
Completion Status NA
Action Code Add
Route
Administration Site
Entering Organization Shoreline Pediatrics
Entered By Sandra Molina
Ordered By Frank Smith

Element Data
Vaccination contraindication current fever with moderate-to-severe illness
Vaccination contraindication/precaution effective date 07/15/2015
Vaccination temporary contraindication/precaution expiration date 08/15/2015

 Vaccine Administration Information - 4
Element Data
Administered Code Hib
Date/Time Start of Administration 07/15/2015
Administered Amount 999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason
Completion Status NA
Action Code Add
Route
Administration Site
Entering Organization Shoreline Pediatrics
Entered By Sandra Molina
Ordered By Frank Smith

Element Data
Vaccination contraindication current fever with moderate-to-severe illness
Vaccination contraindication/precaution effective date 07/15/2015
Vaccination temporary contraindication/precaution expiration date 08/15/2015

 Vaccine Administration Information - 5
Element Data
Administered Code Pneumococcal Conjugate, unspecified formulation
Date/Time Start of Administration 07/15/2015
Administered Amount 999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason
Completion Status NA
Action Code Add
Route
Administration Site
Entering Organization Shoreline Pediatrics
Entered By Sandra Molina
Ordered By Frank Smith

Element Data
Vaccination contraindication current fever with moderate-to-severe illness
Vaccination contraindication/precaution effective date 07/15/2015
Vaccination temporary contraindication/precaution expiration date 08/15/2015

 Vaccine Administration Information - 6
Element Data
Administered Code rotavirus, unspecified formulation
Date/Time Start of Administration 07/15/2015
Administered Amount 999
Administered Units
Administration Notes
Administering Provider
Substance Lot Number
Substance Expiration Date
Substance Manufacturer Name
Substance/Treatment Refusal Reason
Completion Status NA
Action Code Add
Route
Administration Site
Entering Organization Shoreline Pediatrics
Entered By Sandra Molina
Ordered By Frank Smith

Element Data
Vaccination contraindication current fever with moderate-to-severe illness
Vaccination contraindication/precaution effective date 07/15/2015
Vaccination temporary contraindication/precaution expiration date 08/15/2015

5. Display Immunization Report

This test will consist of generating and displaying a human readable immunization report for the patient showing immunization history, upcoming vaccines due.

5.1. Juana Mariana Gonzales Display Immunization Report

Produce an immunization report for the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.)

Test Story

Description
Following the vaccination visit, the provider uses the EMR to produce an immunization report for the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.)

Comments
No Comments

PreCondition
Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. New vaccinations have been administered.

PostCondition
The patient/parent has been provided a patient immunization history report.

Test Objectives
Produce Standard Patient Immunization History Report: The EHR or other clinical software system produces a report of a patient's immunization history that is appropriate for various entities, such as schools and day-care centers.

Evaluation Criteria
No evaluation criteria

Notes to Testers
No Note

5.1.1. Produce an immunization report for Juana Mariana Gonzales including all history

Test Step Type: SUT_MANUAL
The EMR is used to produce an immunization report for the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.).

Test Story

Description

Following the vaccination visit, the provider uses the EMR to produce an immunization report for the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.)

Comments

No Comments

PreCondition

Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. New vaccinations have been administered.

PostCondition

The patient/parent has been provided a patient immunization history report.

Test Objectives

Produce Standard Patient Immunization History Report: The EHR or other clinical software system produces a report of a patient's immunization history that is appropriate for various entities, such as schools and day-care centers.

Evaluation Criteria

The following patient demographics are displayed:

 
Patient Identifier Number:         Vendor Assigned
Patient Identifier Type Code: Vendor Assigned
Patient Name:         Juana Mariana Gonzales
Date/Time of Birth:         12/23/2009 11:05am
 
Sex:                 Female
Patient Address:         4345 Standish Way, Stamford, CT, 06903
Multiple Birth:         N
Birth Order:         NA
 
The following Vaccination History is displayed:
 
Vaccine Group: Hep B Peds NOS
Administered: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08)
ENGERIX-B (NDC 58160-0820-11)"
Date Administered: 12/23/2009
Additional Observations: None
Dose #: 1
Doses in Series: 3
Valid Dose: Y
Ordering Provider: Jane Carter
Entered By: Lisa Sirtis
Entering Organization: Shoreline Hospital
Administered Amt: .05 mL
Administering Provider: Jane Carter
Administered at Location: 325 Shorline Drive, 
Stamford Connecticut 06901
Lot#: 6332FK33
Exp Date: 12/14/2010
Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
 
Vaccine Group: Hep B Peds NOS
Administered: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08)
ENGERIX-B (NDC 58160-0820-11)"
Date Administered: 1/15/2010
Additional Observations: None
Dose #: 2
Doses in Series: 3
Valid Dose: Y
Ordering Provider: Frank Smith
Entered By: Sandra Molina
Entering Organization: Shoreline Pediatrics
Administered Amt: .05 mL
Administering Provider: Sandra Molina
Administered at Location: 400 Shorline Drive, 
Stamford Connecticut 06901
Lot#: 6352FK1
Exp Date: 10/1/2010
Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Right Thigh (HL7 RT)
 
Vaccine Group: Hep B Peds NOS
Administered: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08)
ENGERIX-B (NDC 58160-0820-11)"
Date Administered: 10/30/2010
Additional Observations: None
Dose #: 3
Doses in Series: 3
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: Sandra Molina
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: 6352FK24
Exp Date: 8/31/2012
Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
 
Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)
DAPTACEL (NDC 49281-0286-01)"
Date Administered: 1/22/2010
Additional Observations: None
Dose #: 1
Doses in Series: 5
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: D409QS2341
Exp Date: 11/30/2011
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
 
Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)
DAPTACEL (NDC 49281-0286-01)
Date Administered: 3/23/2010
Additional Observations: 31044-1 Reaction, VXC12^fever of >40.5C (105F) within 48 hours of dose
Dose #: 2
Doses in Series: 5
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: D409QS2433
Exp Date: 9/4/2011
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Right Thigh (HL7 RT)
 
Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)
DAPTACEL (NDC 49281-0286-01)"
Date Administered: 5/22/2010
Additional Observations:
Dose #: 3
Doses in Series: 5
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: D409QS3255
Exp Date: 12/1/2010
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
 
Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)
DAPTACEL (NDC 49281-0286-01)"
Date Administered: 2/21/2011
Additional Observations:
Dose #: 4
Doses in Series: 5
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: D409QS249
Exp Date: 3/1/2011
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Deltoid (HL7 LD)
 
Vaccine Group: Hib, unspecified formulation
Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)
PedvaxHIB (NDC 00006-4897-00)"
Date Administered: 1/22/2010
Additional Observations:
Dose #: 1
Doses in Series: 4
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: 7M54K9245
Exp Date: 3/24/2010
Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)
 
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Right Thigh (HL7 RT)
 
Vaccine Group: Hib, unspecified formulation
Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)
PedvaxHIB (NDC 00006-4897-00)"
Date Administered: 3/23/2010
Additional Observations:
Dose #: 2
Doses in Series: 4
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: 7M55K3342
Exp Date: 10/30/2010
Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)
 
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
 
Vaccine Group: Hib, unspecified formulation
Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)
PedvaxHIB (NDC 00006-4897-00)"
Date Administered: 5/22/2010
Additional Observations:
Dose #: 3
Doses in Series: 4
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: 7M75K4566
Exp Date: 5/23/2010
Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)
 
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Right Thigh (HL7 RT)
 
Vaccine Group: Hib, unspecified formulation
Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)
PedvaxHIB (NDC 00006-4897-00)"
Date Administered: 2/21/2011
Additional Observations:
Dose #: 4
Doses in Series: 4
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: 7M53K5534
Exp Date: 2/22/2011
Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)
 
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Deltoid (HL7 LD)
 
Vaccine Group: poliovirus vaccine, inactivated
Administered: poliovirus vaccine, inactivated (CVX 10)
IPOL (NDC 49281-0860-55)
Date Administered: 1/22/2010
Additional Observations:
Dose #: 1
Doses in Series: 4
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: D333PV2431
Exp Date: 10/4/2010
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Subcutaneous (NCIT C38299, HL70162: SC)
Site: Left Deltoid (HL7 LD)
 
Vaccine Group: poliovirus vaccine, inactivated
Administered: poliovirus vaccine, inactivated (CVX 10)
IPOL (NDC 49281-0860-55)
Date Administered: 3/23/2010
Additional Observations:
Dose #: 2
Doses in Series: 4
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: D333PV4344
Exp Date: 3/23/2010
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Subcutaneous (NCIT C38299, HL70162: SC)
Site: Left Deltoid (HL7 LD)
 
Vaccine Group: pneumococcal, unspecified formulation
Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133)
PREVNAR 13 (NDC 00005-1971-05)"
Date Administered: 1/22/2010
Additional Observations:
Dose #: 1
Doses in Series: 4
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: P243V3281
Exp Date: 1/30/2010
Manufacturer: Pfizer, Inc (MVX PFR)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
 
Vaccine Group: pneumococcal, unspecified formulation
Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133)
PREVNAR 13 (NDC 00005-1971-05)"
Date Administered: 3/23/2010
Additional Observations:
Dose #: 2
Doses in Series: 4
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: P343V8321
Exp Date: 3/30/2010
Manufacturer: Pfizer, Inc (MVX PFR)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
 
Vaccine Group: pneumococcal, unspecified formulation
Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133)
PREVNAR 13 (NDC 00005-1971-05)"
Date Administered: 5/22/2010
Additional Observations:
Dose #: 3
Doses in Series: 4
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: P853V2164
Exp Date: 8/30/2010
Manufacturer: Pfizer, Inc (MVX PFR)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Right Thigh (HL7 RT)
 
Vaccine Group: pneumococcal, unspecified formulation
Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133)
PREVNAR 13 (NDC 00005-1971-05)"
Date Administered: 2/21/2011
Additional Observations:
Dose #: 4
Doses in Series: 4
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: P853V58532
Exp Date: 4/18/2011
Manufacturer: Pfizer, Inc (MVX PFR)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Deltoid (HL7 LD)
 
Vaccine Group: rotavirus, unspecified formulation
Administered: rotavirus, live, monovalent vaccine (CVX 119)
ROTARIX (NDC 58160-0854-52)"
Date Administered: 1/22/2010
Additional Observations:
Dose #: 1
Doses in Series: 3
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: 1 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: 6359RV533
Exp Date: 2/15/2010
Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
 
Vaccine Group: rotavirus, unspecified formulation
Administered: rotavirus, live, monovalent vaccine (CVX 119)
ROTARIX (NDC 58160-0854-52)"
Date Administered: 3/23/2010
Additional Observations:
Dose #: 2
Doses in Series: 3
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: 1 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: 6359RV932
Exp Date: 5/10/2011
Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Right Thigh (HL7 RT)
 
Vaccine Group: influenza, unspecified formulation
Administered: Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161)
FLUZONE QUADRIVALENT (NDC 49281-0514-25)"
Date Administered: 9/25/2010
Additional Observations:
Dose #: 1
Doses in Series: 2
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .25 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: D8043IN8734
Exp Date: 3/12/2011
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
 
Vaccine Group: influenza, unspecified formulation
Administered: Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161)
FLUZONE QUADRIVALENT (NDC 49281-0514-25)"
Date Administered: 10/27/2010
Additional Observations:
Dose #: 2
Doses in Series: 2
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .25 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: D8043IN8734
Exp Date: 3/12/2011
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Right Thigh (HL7 RT)
 
Vaccine Group: influenza, unspecified formulation
Administered: Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161)
FLUZONE QUADRIVALENT (NDC 49281-0514-25)"
Date Administered: 10/2/2011
Additional Observations:
Dose #:
Doses in Series:
Valid Dose:
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .25 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: D9334IN9333
Exp Date: 5/22/2012
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Deltoid (HL7 LD)
 
Vaccine Group: influenza, unspecified formulation
Administered: Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161)
FLUZONE QUADRIVALENT (NDC 49281-0514-25)"
Date Administered: 11/4/2012
Additional Observations:
Dose #:
Doses in Series:
Valid Dose:
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .25 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: D9553IN2243
Exp Date: 4/30/2012
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Deltoid (HL7 LD)
 
Vaccine Group: influenza, unspecified formulation
Administered: influenza, live, intranasal, quadrivalent (CVX 149)
FluMist Quadrivalent (NDC 66019-0301-10)"
Date Administered: Current Date
Additional Observations:
Dose #:
Doses in Series:
Valid Dose:
Ordering Provider: Sandra Molina
Entered By: Frank Smith
Entering Organization: Oceanview Pediatrics
Administered Amt: .2 mL
Administering Provider: Sandra Molina
Administered at Location: 400 Shoreline Drive, Stamford Connecticut 06901
Lot#: 8L4B3521
Exp Date: 7/15/2015
Manufacturer: MedImmune,LLC (MVX MED)
Route: Nasal (NCIT C38284), Nasal (HL70162 NS)
Site:
 
Vaccine Group: Hep A, unspecified formulation
Administered: hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule (CVX 83)
HAVRIX (NDC 58160-0825-52)"
Date Administered: 11/23/2011
Additional Observations:
Dose #: 1
Doses in Series: 2
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: 6359RT33
Exp Date: 1/4/2012
Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Right Deltoid (HL7 RD)
 
Vaccine Group: Hep A, unspecified formulation
Administered: hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule (CVX 83)
HAVRIX (NDC 58160-0825-52)"
Date Administered: 5/23/2012
Additional Observations:
Dose #: 2
Doses in Series: 2
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: 6359RT48
Exp Date: 9/11/2012
Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Deltoid (HL7 LD)
 
Vaccine Group: MMRV
Administered: measles, mumps, rubella, and varicella virus vaccine (CVX 94)
ProQuad (NDC 00006-4999-00)"
Date Administered: 10/23/2010
Additional Observations:
Dose #:
Doses in Series: 2
Valid Dose: N
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: 7W27V7491
Exp Date: 12/15/2010
Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)
 
Route: Subcutaneous (NCIT C38299, HL70162: SC)
Site: Left Thigh (HL7 LT)
 
Vaccine Group: MMRV
Administered: measles, mumps, rubella, and varicella virus vaccine (CVX 94)
ProQuad (NDC 00006-4999-00)"
Date Administered: 11/22/2012
Additional Observations:
Dose #: 1
Doses in Series: 2
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: 7W87V3452
Exp Date: 4/13/2013
Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)
 
Route: Subcutaneous (NCIT C38299, HL70162: SC)
Site: Left Deltoid (HL7 LD)
 
Vaccine Group: MMRV
Administered: measles, mumps, rubella, and varicella virus vaccine (CVX 94)
ProQuad (NDC 00006-4999-00)"
Date Administered: Current Date
Additional Observations: Reaction (LOINC 31044-1)/fever of >40.5C (105F) within 48 hours of dose (CDCPHINVS VXC12)
Dose #: 2
Doses in Series: 2
Valid Dose: Y
Ordering Provider: Sandra Molina
Entered By: Frank Smith
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: Sandra Molina
Administered at Location: 400 Shoreline Drive, Stamford Connecticut 06901
Lot#: 7W87V3687
Exp Date: 7/15/2015
Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)
Route: Subcutaneous (NCIT C38299, HL70162: SC)
Site: Left Deltoid (HL7 LD)
 
The Following Vaccine Forecast is displayed:
 
Vaccine Group: IPV
Due Date: 11/22/2013
Earliest Date to Give: 11/22/2013
Latest Date to Give: 11/22/2015
Overdue Date: 11/23/2015
Immunization Schedule: ACIP
 
 
Vaccine Group: influenza, unspecified formulation
Due Date: 10/21/2016
Earliest Date to Give: 9/1/2016
Latest Date to Give: 2/29/2017
Overdue Date: 3/1/3027
Immunization Schedule: ACIP
 

Notes to Testers

No Note

5.2. Juan Marcel Gonzales Display Immunization Report

Produce an immunization report for the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.)

Test Story

Description
Following the vaccination visit, the provider uses the EMR to produce an immunization report for the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.)

Comments
No Comments

PreCondition
Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. New vaccinations have been administered.

PostCondition
The patient/parent has been provided a patient immunization history report.

Test Objectives
Produce Standard Patient Immunization History Report: The EHR or other clinical software system produces a report of a patient's immunization history that is appropriate for various entities, such as schools and day-care centers.

Evaluation Criteria
No evaluation criteria

Notes to Testers
No Note

5.2.1. Produce an immunization report for Juan Marcel Gonzales including all history

Test Step Type: SUT_MANUAL
The EMR is used to produce an immunization report for the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.).

Test Story

Description

Following the vaccination visit, the provider uses the EMR to produce an immunization report for the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.)

Comments

No Comments

PreCondition

Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. New vaccinations have been administered.

PostCondition

The patient/parent has been provided a patient immunization history report.

Test Objectives

Produce Standard Patient Immunization History Report: The EHR or other clinical software system produces a report of a patient's immunization history that is appropriate for various entities, such as schools and day-care centers.

Evaluation Criteria
The following patient demographics are displayed:
Patient Identifier Number: Vendor Assigned
Patient Identifier Type Code: Vendor Assigned
Patient Name: Juan Marcel Gonzales
Date/Time of Birth: 11/23/2011 11:00am
Sex: Male
Patient Address: 4623 Standish Way, Stamford, CT 06903
Multiple Birth: N
Birth Order: NA
 
The following Vaccination History is displayed:
Vaccine Group: Hep B Peds NOS
Administered: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08)
ENGERIX-B (NDC 58160-0820-11)"
Date Administered: 11/23/2011
Additional Observations:
Dose #: 1
Doses in Series: 3
Valid Dose: Y
Ordering Provider: Jane Carter
Entered By: Lisa Sirtis
Entering Organization: Shoreline Hospital
Administered Amt: .05 mL
Administering Provider: Jane Carter
Administered at Location: 325 Shorline Drive, 
Stamford Connecticut 06901
Lot#: 6332FK34
Exp Date: 12/14/2011
Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
 
Vaccine Group: Hep B Peds NOS
Administered: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08)
ENGERIX-B (NDC 58160-0820-11)"
Date Administered: 12/23/2013
Additional Observations:
Dose #: 2
Doses in Series: 3
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: 6352FK2
Exp Date: 10/1/2011
Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Right Thigh (HL7 RT)
 
Vaccine Group: Hep B Peds NOS
Administered: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08)
ENGERIX-B (NDC 58160-0820-11)"
Date Administered: Current Date
Additional Observations:
Dose #: 3
Doses in Series: 3
Valid Dose: Y
Ordering Provider: Sandra Molina
Entered By: Frank Smith
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: Sandra Molina
Administered at Location: 400 Shoreline Drive, Stamford Connecticut 06901
Lot#: 6332FK26
Exp Date: 8/25/2015
Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Deltoid (HL70162 LD)
 
Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)
DAPTACEL (NDC 49281-0286-01)"
Date Administered: 1/22/2012
Additional Observations:
Dose #: 1
Doses in Series: 5
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: D409QS2342
Exp Date: 11/30/2012
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
 
Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)
DAPTACEL (NDC 49281-0286-01)"
Date Administered: 3/22/2012
Additional Observations:
Dose #: 2
Doses in Series: 5
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: D409QS2434
Exp Date: 9/4/2012
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Right Thigh (HL7 RT)
 
Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)
DAPTACEL (NDC 49281-0286-01)"
Date Administered: 5/21/2012
Additional Observations:
Dose #: 3
Doses in Series: 5
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: D409QS3256
Exp Date: 12/1/2012
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
 
 
Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)
DAPTACEL (NDC 49281-0286-01)"
Date Administered: 5/21/2012
Additional Observations:
Dose #: 3
Doses in Series: 5
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: D409QS3256
Exp Date: 12/1/2012
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
 
Vaccine Group: Hib, unspecified formulation
Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)
PedvaxHIB (NDC 00006-4897-00)"
Date Administered: 1/22/2012
Additional Observations:
Dose #: 1
Doses in Series: 4
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: 7M54K9255
Exp Date: 3/24/2012
Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)
 
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Right Thigh (HL7 RT)
 
Vaccine Group: Hib, unspecified formulation
Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)
PedvaxHIB (NDC 00006-4897-00)"
Date Administered: 3/22/2012
Additional Observations:
Dose #: 2
Doses in Series: 4
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: 7M55K3343
Exp Date: 10/30/2012
Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)
 
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
 
Vaccine Group: Hib, unspecified formulation
Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)
PedvaxHIB (NDC 00006-4897-00)"
Date Administered: 5/21/2012
Additional Observations:
Dose #: 3
Doses in Series: 4
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: 7M75K4577
Exp Date: 5/23/2012
Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)
 
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Right Thigh (HL7 RT)
 
Vaccine Group: Hib, unspecified formulation
Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)
PedvaxHIB (NDC 00006-4897-00)"
Date Administered: 11/22/2012
Additional Observations:
Dose #: 4
Doses in Series: 4
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: 7M53K5535
Exp Date: 2/22/2012
Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)
 
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Deltoid (HL7 LD)
 
Vaccine Group: poliovirus vaccine, inactivated
Administered: poliovirus vaccine, inactivated (CVX 10)
IPOL (NDC 49281-0860-55)"
Date Administered: 1/22/2012
Additional Observations:
Dose #: 1
Doses in Series: 4
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: D333PV2444
Exp Date: 10/4/2012
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Subcutaneous (NCIT C38299, HL70162: SC)
Site: Left Deltoid (HL7 LD)
 
Vaccine Group: poliovirus vaccine, inactivated
Administered: poliovirus vaccine, inactivated (CVX 10)
IPOL (NDC 49281-0860-55)"
Date Administered: 3/22/2012
Additional Observations:
Dose #: 2
Doses in Series: 4
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: D333PV4343
Exp Date: 3/23/2012
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Subcutaneous (NCIT C38299, HL70162: SC)
Site: Left Deltoid (HL7 LD)
 
Vaccine Group: poliovirus vaccine, inactivated
Administered: poliovirus vaccine, inactivated (CVX 10)
IPOL (NDC 49281-0860-55)
Date Administered: 5/21/2012
Additional Observations:
Dose #: 2
Doses in Series: 4
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: D335PV9654
Exp Date: 2/22/2013
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Subcutaneous (NCIT C38299, HL70162: SC)
Site: Left Deltoid (HL7 LD)
 
Vaccine Group: pneumococcal, unspecified formulation
Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133)
PREVNAR 13 (NDC 00005-1971-05)"
Date Administered: 1/22/2012
Additional Observations:
Dose #: 1
Doses in Series: 4
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: P243V3321
Exp Date: 1/30/2012
Manufacturer: Pfizer, Inc (MVX PFR)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
 
Vaccine Group: pneumococcal, unspecified formulation
Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133)
PREVNAR 13 (NDC 00005-1971-05)"
Date Administered: 3/22/2012
Additional Observations:
Dose #: 2
Doses in Series: 4
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: P343V8445
Exp Date: 3/30/2012
Manufacturer: Pfizer, Inc (MVX PFR)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
 
Vaccine Group: pneumococcal, unspecified formulation
Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133)
PREVNAR 13 (NDC 00005-1971-05)"
Date Administered: 5/21/2012
Additional Observations:
Dose #: 3
Doses in Series: 4
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: P853V2175
Exp Date: 8/30/2012
Manufacturer: Pfizer, Inc (MVX PFR)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Right Thigh (HL7 RT)
 
Vaccine Group: pneumococcal, unspecified formulation
Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133)
PREVNAR 13 (NDC 00005-1971-05)"
Date Administered: 11/22/2012
Additional Observations:
Dose #: 4
Doses in Series: 4
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: P853V58544
Exp Date: 4/18/2013
Manufacturer: Pfizer, Inc (MVX PFR)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Deltoid (HL7 LD)
 
Vaccine Group: rotavirus, unspecified formulation
Administered: rotavirus, live, monovalent vaccine (CVX 119)
ROTARIX (NDC 58160-0854-52)"
Date Administered: 1/22/2012
Additional Observations:
Dose #: 1
Doses in Series: 3
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: 1 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: 6359RV533
Exp Date: 2/15/2010
Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
 
Vaccine Group: rotavirus, unspecified formulation
Administered: rotavirus, live, monovalent vaccine (CVX 119)
ROTARIX (NDC 58160-0854-52)"
Date Administered: 3/22/2012
Additional Observations:
Dose #: 2
Doses in Series: 3
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: 1 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: 6359RV932
Exp Date: 5/10/2011
Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Right Thigh (HL7 RT)
 
Vaccine Group: influenza, unspecified formulation
Administered: Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161)
FLUZONE QUADRIVALENT (NDC 49281-0514-25)"
Date Administered: 9/22/2012
Additional Observations:
Dose #: 1
Doses in Series: 2
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .25 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: D8043IN8734
Exp Date: 3/12/2013
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
 
Vaccine Group: influenza, unspecified formulation
Administered: Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161)
FLUZONE QUADRIVALENT (NDC 49281-0514-25)"
Date Administered: 10/20/2012
Additional Observations:
Dose #: 2
Doses in Series: 2
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .25 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: D8043IN8798
Exp Date: 3/12/2013
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Right Thigh (HL7 RT)
 
Vaccine Group: influenza, unspecified formulation
Administered: Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161)
FLUZONE QUADRIVALENT (NDC 49281-0514-25)"
Date Administered: 10/30/2013
Additional Observations:
Dose #:
Doses in Series:
Valid Dose:
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .25 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: D8043IN8734
Exp Date: 5/22/2014
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Deltoid (HL7 LD)
 
Vaccine Group: influenza, unspecified formulation
Administered: Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161)
FLUZONE QUADRIVALENT (NDC 49281-0514-25)"
Date Administered: Current Date
Additional Observations:
Dose #:
Doses in Series:
Valid Dose:
Ordering Provider: Sandra Molina
Entered By: Frank Smith
Entering Organization: Oceanview Pediatrics
Administered Amt: .25 mL
Administering Provider: Sandra Molina
Administered at Location: 400 Shoreline Drive, Stamford Connecticut 06901
Lot#: D8043IN8855
Exp Date: 7/28/2015
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
 
Vaccine Group: Hep A, unspecified formulation
Administered: hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule (CVX 83)
HAVRIX (NDC 58160-0825-52)"
Date Administered: 5/21/2013
Additional Observations:
Dose #: 1
Doses in Series: 2
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: 6359RT35
Exp Date: 1/4/2014
Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Right Deltoid (HL7 RD)
 
Vaccine Group: Hep A, unspecified formulation
Administered: hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule (CVX 83)
HAVRIX (NDC 58160-0825-52)"
Date Administered: 12/1/2013
Additional Observations:
Dose #: 2
Doses in Series: 2
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: 6359RT47
Exp Date: 9/11/2013
Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Deltoid (HL7 LD)
 
Vaccine Group: MMRV
Administered: measles, mumps, rubella, and varicella virus vaccine (CVX 94)
ProQuad (NDC 00006-4999-00)"
Date Administered: 11/22/2012
Additional Observations:
Dose #: 1
Doses in Series: 2
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: 7W27V7632
Exp Date: 12/15/2016
Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)
 
Route: Subcutaneous (NCIT C38299, HL70162: SC)
Site: Left Thigh (HL7 LT)
 
The Following Vaccine Forecast is displayed:
Vaccine Group: Dtap
Due Date: 11/22/2015
Earliest Date to Give: 11/22/2015
Latest Date to Give: 11/21/2017
Overdue Date: 11/22/2017
Immunization Schedule: ACIP
 
Vaccine Group: IPV
Due Date: 11/22/2015
Earliest Date to Give: 11/22/2015
Latest Date to Give: 11/21/2017
Overdue Date: 11/22/2017
Immunization Schedule: ACIP
 
Vaccine Group: Influenza
Due Date: 10/22/2015
Earliest Date to Give: 9/1/2015
Latest Date to Give: 1/31/2016
Overdue Date: 2/1/2016
Immunization Schedule: ACIP
 
Vaccine Group: MMR
Due Date: 11/22/2015
Earliest Date to Give: 11/22/2015
Latest Date to Give: 11/21/2017
Overdue Date: 11/22/2017
Immunization Schedule: ACIP
 
Vaccine Group: Varicella
Due Date: 11/22/2015
Earliest Date to Give: 11/22/2015
Latest Date to Give: 11/21/2017
Overdue Date: 11/22/2017
Immunization Schedule: ACIP

Notes to Testers

No Note

5.3. Mariana Gonzales Morales Display Immunization Report

Produce an immunization report for the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.)

Test Story

Description
Following the vaccination visit, the provider uses the EMR to produce an immunization report for the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.)

Comments
No Comments

PreCondition
Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. New vaccinations have been administered.

PostCondition
The patient/parent has been provided a patient immunization history report.

Test Objectives
Produce Standard Patient Immunization History Report: The EHR or other clinical software system produces a report of a patient's immunization history that is appropriate for various entities, such as schools and day-care centers.

Evaluation Criteria
No evaluation criteria

Notes to Testers
No Note

5.3.1. Produce an immunization report for Juan Marcel Gonzales including all history

Test Step Type: SUT_MANUAL
The EMR is used to produce an immunization report for the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.).

Test Story

Description

Following the vaccination visit, the provider uses the EMR to produce an immunization report for the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.)

Comments

No Comments

PreCondition

Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. New vaccinations have been administered.

PostCondition

The patient/parent has been provided a patient immunization history report.

Test Objectives

Produce Standard Patient Immunization History Report: The EHR or other clinical software system produces a report of a patient's immunization history that is appropriate for various entities, such as schools and day-care centers.

Evaluation Criteria
The following patient demographics are displayed:
Patient Identifier Number: Vendor Supplied
Patient Identifier Type Code: Vendor Supplied
Patient Name: Mariela Gonzales Morales
Date/Time of Birth: 03/30/2015 11:00am
Sex: Female
Patient Address: 3321 Standish Way, Stamford, CT 06903
Multiple Birth: Y
Birth Order: 1
 
The following Vaccination History is displayed:
Vaccine Group: Hep B Peds NOS
Administered: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08)
ENGERIX-B (NDC 58160-0820-11)"
Date Administered: 11/23/2011
Additional Observations:
Dose #: 1
Doses in Series: 3
Valid Dose: Y
Ordering Provider: Jane Carter
Entered By: Lisa Sirtis
Entering Organization: Shoreline Hospital
Administered Amt: .05 mL
Administering Provider: Jane Carter
Administered at Location: 325 Shorline Drive, 
Stamford Connecticut 06901
Lot#: 6332FK34
Exp Date: 12/14/2011
Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
 
The Following Vaccine Forecast is displayed:
Vaccine Group: Hep B Peds NOS
Due Date: 6/29/2015
Earliest Date to Give: 6/29/2015
Latest Date to Give: 7/29/2015
Overdue Date: 7/30/2015
Immunization Schedule: ACIP
 
Vaccine Group: Dtap
Due Date: 7/29/2015
Earliest Date to Give: 29-Jul-15
Latest Date to Give:
Overdue Date:
Immunization Schedule: ACIP
 
Vaccine Group: Hib
Due Date: 7/29/2015
Earliest Date to Give: 7/29/2015
Latest Date to Give:
Overdue Date:
Immunization Schedule: ACIP
 
Vaccine Group: IPV
Due Date: 7/29/2015
Earliest Date to Give: 7/29/2015
Latest Date to Give:
Overdue Date:
Immunization Schedule: ACIP
 
Vaccine Group: Pneumococcal conjugate
Due Date: 7/29/2015
Earliest Date to Give: 7/29/2015
Latest Date to Give:
Overdue Date:
Immunization Schedule: ACIP
 
Vaccine Group: Rotavirus
Due Date: 7/29/2015
Earliest Date to Give: 7/29/2015
Latest Date to Give:
Overdue Date:
Immunization Schedule: ACIP
 
Vaccine Group: Influenza
Due Date: Nov 26, 2015 or later 
later
Earliest Date to Give: Nov 26, 2015
 
Latest Date to Give:
Overdue Date:
Immunization Schedule: ACIP
 
Vaccine Group: HepA
Due Date: 5/29/2016
Earliest Date to Give: 5/29/2016
Latest Date to Give: 5/29/2017
Overdue Date: 5/30/2017
Immunization Schedule: ACIP
 
Vaccine Group: MMR
Due Date: 5/29/2016
Earliest Date to Give: 5/29/2016
Latest Date to Give: 8/27/2016
Overdue Date: 8/28/2016
Immunization Schedule: ACIP
 
Vaccine Group: Varicella
Due Date: 5/29/2016
Earliest Date to Give: 5/29/2016
Latest Date to Give: 8/27/2016
Overdue Date: 8/28/2016
Immunization Schedule: ACIP
 

Notes to Testers

No Note

6. Cohort Report

This test will consist of generating a cohort report to list all patients who are overdue for immunizations showing all overdue immunizations with the associated due/overdue dates.

6.1. Overdue Immunizations

List all patients who are overdue for immunizations showing all overdue immunizations.

Test Story

Description

The provider periodically uses the EMR to identify the cohort of patients that are overdue for immunizations along with their contact information in order to send reminder notifications to the patients/parents.

Comments

No Comments

PreCondition

Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. The vaccine forecast is available to the EMR.

PostCondition

The Cohort report for all patients that are overdue for immunizations is available to the provider through the EMR.

Test Objectives

Produce Population-Level Report: The EHR or other clinical system generates aggregate, population-level reports based on known patient immunization data.

Evaluation Criteria

The following patient information is provided on the cohort report:

 
Patient Name   Mariela Gonzales Morales
Preferred Contact Method   Phone
Contact information using preferred contact (email, text, phone, mailing address)   (203) 555-1214
Patient Identifier Number   Vendor Supplied
Patient Identifier Type Code      Vendor Supplied
Date/Time of Birth   3/30/2015 11am
Sex  Female
Vaccine Group  Hep B Peds NOS
Latest Date to Give  5/29/15
Overdue Date  5/29/15
Dose #  2
Dose in Series  3
Link to full record  Vendor Supplied
   
Patient Name  Juana Maria Gonzales Morales
Preferred Contact Method  Phone
Contact information using preferred contact (email, text, phone, mailing address)   (203) 555-1214
Patient Identifier Number   Vendor Supplied
Patient Identifier Type Code   Vendor Supplied
Date/Time of Birth   3/30/2015 11:15am
Sex   Female
Vaccine Group   Hep B Peds NOS
Latest Date to Give   5/29/15
Overdue Date   5/29/15
Dose #     2
Dose in Series    3
Link to full record   Vendor Supplied

Notes to Testers

No Note

6.1.1. Produce Overdue Immunizations Cohort Report

Test Step Type: SUT_MANUAL
The provider uses the EMR to create a report for all patient vaccinations overdue with the contact information.

Test Story

Description
The provider periodically uses the EMR to identify the cohort of patients that are overdue for immunizations along with their contact information in order to send reminder notifications to the patients/parents.
 

Comments

No Comments

PreCondition
Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. The vaccine forecast is available to the EMR.
 

PostCondition

The Cohort report for all patients that are overdue for immunizations is available to the provider through the EMR.

Test Objectives

Produce Population-Level Report: The EHR or other clinical system generates aggregate, population-level reports based on known patient immunization data.

Evaluation Criteria

The following patient information is provided on the cohort report:

 
Patient Name   Mariela Gonzales Morales
Preferred Contact Method   Phone
Contact information using preferred contact (email, text, phone, mailing address)   (203) 555-1214
Patient Identifier Number   Vendor Supplied
Patient Identifier Type Code      Vendor Supplied
Date/Time of Birth   5/30/2015 11am
Sex  Female
Vaccine Group  Hep B Peds NOS
Latest Date to Give  5/29/15
Overdue Date  5/29/15
Dose #  2
Dose in Series  3
Link to full record  Vendor Supplied
   
Patient Name  Juana Maria Gonzales Morales
Preferred Contact Method  Phone
Contact information using preferred contact (email, text, phone, mailing address)   (203) 555-1214
Patient Identifier Number   Vendor Supplied
Patient Identifier Type Code   Vendor Supplied
Date/Time of Birth   5/30/2015 11:15am
Sex   Female
Vaccine Group   Hep B Peds NOS
Latest Date to Give  5/29/15
Overdue Date   5/29/15
Dose #     2
Dose in Series    3
Link to full record   Vendor Supplied

Notes to Testers

No Note